Search

Suicide is a complex multifactorial process influenced by a variety of biological, psychological, and social stressors. Many older adults face a characteristic set of challenges that predispose them to suicidal ideation, suicide-related behavior, and death by suicide. This study explored the subjective experience of suicidality through the analysis of suicide notes from older adults.Qualitative study analyzing written suicide notes.Written notes for suicide deaths in Toronto, Canada, between 2003 and 2009 were obtained from the Office of the Chief Coroner for Ontario.The analysis comprised 29 suicide notes (mean words per note: 221; range: 6-1095) written by individuals 65 years and older (mean ± SD age: 76.2 ± 8.3).We employed a constructivist grounded theory framework for the analysis, conducted through line-by-line open coding, axial coding, and theorizing of data to establish themes.Suicide notes elucidated the writers' conception of suicide and their emotional responses to stressors. Expressed narratives contributing to suicide centered on burdensomeness or guilt, experiences of mental illness, loneliness or isolation, and poor physical health or disability. Terms related to pain, poor sleep, apology, and inability to go on were recurrent.Suicide notes enrich our understanding of the thoughts and emotions of those at highest risk of suicide, and they inform potential interventions for reducing suicide risk in older adults.

Rates of alcohol use and alcohol-related harms increase with greater alcohol availability. However, regional differences in sociodemographic characteristics and built environment may affect this association. This study evaluated the association between off-premise alcohol availability and alcohol use in Ontario, Canada, and the degree to which this association varies between cities.This was a cross-sectional spatial analysis of urban neighborhoods in Ontario, Canada (There was an overall positive association between alcohol availability and high-volume alcohol use (male coefficient estimate (β) = 0.19, 95% credible interval [CI] [0.16, 0.22]; female β = 0.17, 95% CI [0.13, 0.21]). However, the association was eliminated in models that allowed for this association to vary between cities via an interaction term (male β = -0.04, 95% CI [-0.26, 0.19]; female β = -0.04, 95% CI [-0.34, 0.26]). This was explained by variability in the association between cities, where some cities demonstrated a positive association between availability and use and others demonstrated a negative association.Although there is a province-wide positive association between off-premise alcohol availability and high-volume alcohol use, there is substantial regional variation in this association that may affect the local effectiveness of alcohol regulation policies.

Objectives A patient's death by suicide is a common experience for psychiatrists, ranging from 33% to 80%, however, research about the impact of patient suicide on psychiatrists is limited to a few survey studies. This study had three main objectives: (1) understanding the emotional and behavioural impact of a patient's suicide on psychiatrists, (2) exploring if and how the experience of a patient's suicide results in changes in psychiatrist practice patterns, and (3) understanding the tangible steps that psychiatrists and institutions take to manage the emotional and behavioural impact of patient suicide on psychiatrists. Methods Eighteen psychiatrists were recruited using snowball sampling and interviewed to collect demographic data, followed by an in-depth exploration of their experiences of patient suicide. Interviews were then transcribed verbatim and analysed using constructivist grounded theory. Results Study participants described strong emotional reactions in response to patient suicide. Emotional reactions were mediated by a physician, patient, relationship and institutional factors. While psychiatrists did not change the acuity or setting of their practice in response to patient suicide, they made several changes in their practice, including increased caution regarding discharges and passes from inpatient units, more thorough documentation and continuing education about suicide. Conclusions Patient suicide has a profound impact on psychiatrists and based on the findings of this study, we propose steps that psychiatrists and institutions can take to manage the emotional, psychological and behavioural burden of this event.

This study aims to determine the relationship between rurality and help-seeking behavior prior to a suicide or suicide attempt.Data from 2007 to 2017 were obtained from administrative databases held at ICES, which capture all hospital, emergency department (ED), and general practitioner (GP) visits across Ontario. Rurality was defined using the Rurality Index of Ontario scores. Help-seeking was based on accessing health services 1 year prior to the event.Among those who died by suicide (N = 9848), those living in rural areas were less likely to seek help from a psychiatrist (rural males: AOR = 0.42, 95% CI = 0.31-0.57; rural females: AOR = 0.46, 95% CI = 0.29-0.97) compared with those living in urban areas. We found a similar association among those who attempted suicide (N = 82,480) (rural males: AOR = 0.49, 95% CI = 0.43-0.56; rural females: AOR = 0.51, 95% CI = 0.46-0.57). Rural males and females were more likely to seek care from an ED for mental health reasons compared with urban males and females.Among people who died by suicide, those living in rural areas are generally less likely to access psychiatrists and GPs and more likely to access EDs, suggesting that people living in rural areas may have less access to care than their urban counterparts.

Objectives Youth face numerous challenges in receiving coordinated and continuous mental health services, particularly as they reach the age of transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). The Longitudinal Youth in Transition Study (LYiTS) follows youth prospectively as they cross this transition boundary to better understand their transition pathways and resulting symptoms and health service use outcomes. The current paper presents the baseline profile description for the LYiTS cohort and additionally examines differences in symptoms and functioning and health service utilization between youth receiving services at hospital- versus community-based CAMHS. Methods A cross-sectional design was used. A sample of 237 16–18-year-old youth recruited from outpatient CAMHS at two hospitals and two community sites completed self-report measures at their first of four annual assessments. A latent profile analysis was conducted to identify symptomology profiles, and youth were compared on symptoms and health service use between hospital- and community-based sites. Results Four distinct symptomology profiles were identified (subclinical, moderate internalizing, moderate externalizing, and high symptomology). Symptom profiles and functioning levels reported by youth were no different across both types of organization, although there were differences detected in health service utilization, such as type of provider seen and use of medications. Conclusions These findings suggest that there is little difference in symptomology between youth accessing hospital versus community-based CAMHS. With growing interest in understanding the effectiveness and cost-effectiveness of different models of mental health care, these findings provide a new understanding of the clinical and service use profiles of transition-aged youth that will be explored further as this cohort is followed across the CAMHS to AMHS transition boundary.

This study examined a 2-year period following an eating disorder (ED) diagnosis in order to determine patterns of health care utilization.We conducted a retrospective cohort study of children (n = 1560) diagnosed with an ED between 2000 and 2017. The ED diagnosis was made at a tertiary level hospital for children and adolescents presenting for outpatient assessment by specialist adolescent medicine physicians and recorded in a program database over this period of time. We then created three sex- and age-matched comparison cohorts using provincial health administrative databases including: a general population cohort, a diabetes cohort (to compare nonmental health care utilization) and a mood disorder cohort (to compare mental health care utilization). Outcomes included hospitalizations, emergency department visits, as well as general practitioner, psychiatrist, and pediatrician visits. Odds ratios (dichotomous outcomes) and rate ratios (continuous outcomes) were calculated.Compared to the general population cohort, the ED cohort had higher odds and rates of all types of health care utilization. Compared to the diabetes cohort, the ED cohort had higher odds of nonmental health-related admissions (OR 1.45, 95% CI 1.09-1.95) and higher rates of nonmental health-related emergency department visits (RR 1.59, 95% CI 1.18-2.13). Compared to the mood disorder cohort, the ED cohort had higher rates of pediatrician visits, which were mental health-related (RR 14.88, 95% CI 10.64-20.82), however most other types of mental health service utilization were lower.These patterns indicate that the service needs of young people diagnosed with EDs are higher than those with diabetes with respect to nonmental health admissions and emergency department visits, while in terms of mental health service utilization, there appears to be a lack of use of mental health services compared to youth with mood disorders with the exception of pediatrician mental health visits. These findings must be interpreted in the context of under-detection and under-treatment of EDs.Our study found that the health service needs of young people with EDs are higher than those with diabetes with respect to admissions and emergency department visits, while there appears to be a lack of use of mental health services compared to youth with mood disorders with the exception of pediatrician mental health visits.

Background We previously found an association between rurality and death by suicide, where those living in rural areas were more likely to die by suicide. One potential reason why this relationship exists might be travel time to care. This paper examines the relationship between travel time to both psychiatric and general hospitals and suicide, and then determine whether travel time to care mediates the relationship between rurality and suicide. Methods This is a population-based nested case-control study. Data from 2007 to 2017 were obtained from administrative databases held at ICES, which capture all hospital and emergency department visits across Ontario. Suicides were captured using vital statistics. Travel time to care was calculated from the resident’s home to the nearest hospital based on the postal codes of both locations. Rurality was measured using Metropolitan Influence Zones. Results For every hour in travel time a male resides from a general hospital, their risk of death by suicide doubles (AOR = 2.08, 95% CI = 1.61–2.69). Longer travel times to psychiatric hospitals also increases risk of suicide among males (AOR = 1.03, 95%CI = 1.02–1.05). Travel time to general hospitals is a significant mediator of the relationship between rurality and suicide among males, accounting for 6.52% of the relationship between rurality and increased risk of suicide. However, we also found that there is effect modification, where the relationship between travel time and suicide is only significant among males living in urban areas. Conclusions Overall, these findings suggest that males who must travel longer to hospitals are at a greater risk of suicide compared to those who travel a shorter time. Furthermore, travel time to care is a mediator of the association between rurality and suicide among males.

Little is known about the health care costs of individuals with chronic psychotic disorders who experience incarceration. This study sought to address this knowledge gap.The authors analyzed linked 2007-2010 correctional and administrative health care data on sex- and age-matched individuals with chronic psychotic disorders with and without known incarceration in prison for up to 2 years in the Ontario correctional system. Mean 1-year health care costs (overall and by sex) in the year before incarceration (when release occurred in 2010) were estimated from third-party payer data and compared between the two groups. Costs were calculated in 2018 Canadian dollars.Individuals who experienced incarceration (N=3,197) had mean 1-year costs of $15,728 in the year before incarceration, whereas those who did not (N=6,393) had 1-year costs of $11,588. This difference was mostly due to costs arising from psychiatric hospitalizations, emergency department visits, and physician services. The main factors associated with the difference were incarceration in the following year (increase of $4,827, p0.001), being age 18-29 years compared with ages 30-39 or 40-49 (increase of $4,448 and $4,218, respectively, p0.001), and chronic psychotic disorder duration of 1-2 years compared with ≤1 year duration (increase of $6,812, p=0.004). Women who experienced incarceration had higher costs than incarcerated men ($20,648 vs. $14,763).Individuals with chronic psychotic disorders who experienced incarceration had higher health care costs than comparable individuals who did not. These higher health care costs may signal the need for interventions and policies that help individuals with psychotic disorders avoid criminal justice system involvement.

Transgender individuals experience significant oppression resulting in mental health disparities. Factors associated with their need for acute mental health care are unknown. This study compared characteristics of transgender individuals who presented for acute mental health care with population-based comparison samples.This cross-sectional study examined transgender individuals who had a mental health-related emergency department (ED) visit (N=728) or hospitalization (N=454). Transgender individuals were identified, and their data were linked with health administrative data. The transgender ED and hospitalization samples were each compared with two samples: all individuals in Ontario who had an ED visit or hospitalization (unmatched) and individuals matched on age, region of residence, and mental health care utilization history. Individuals' sociodemographic and clinical factors were compared.After matching, transgender individuals in the ED sample were more likely than those in the comparison group to be in the lowest neighborhood income quintile (37% versus 27%) and the highest residential instability quintile (47% versus 38%) and to be diagnosed as having a mood (26% versus 19%) or personality disorder (4% versus 1%). Transgender individuals in the hospitalization sample were more likely to be in the lowest neighborhood income quintile (36% versus 27%) and the highest residential instability quintile (45% versus 35%) and to be diagnosed as having a mood (40% versus 35%) or personality disorder (5% versus 2%).Transgender individuals who accessed acute mental health care had unique sociodemographic and clinical factors associated with their presentation that persisted after matching. More research into the factors associated with their acute care presentation is warranted, including how experiences of marginalization play a role.

To investigate the impact of restrictions on access to long acting oxycodone on prescription opioid use and opioid-related harms.Administrative health data from Ontario, Canada was used to measure differences in opioids dispensed and emergency department (ED) visits for opioid-related overdose, poisoning, or substance use following provincial restrictions on access to publicly insured OxyContin (February 29, 2012) and OxyNeo (February 28, 2013). This study focused on the cohort of provincial drug insurance eligible people (people 65+ and select low-income populations) who were dispensed oxycodone prior to the restrictions. Difference-in-differences models with a propensity score matched comparison group of people who were dispensed non-oxycodone opioids were used to estimate the main effects.In 6 months following the delisting of OxyContin, milligrams of morphine equivalents (MMEs) per person per week for all opioids fell by an average of 7.5% in people dispensed oxycodone relative to the comparison group, and an average of 13.8% in chronic recipients of oxycodone. In the 6 months following the restrictions on OxyNeo, MMEs per person per week fell by an average of 3.1% in all people dispensed oxycodone, and 25.2% in chronic oxycodone recipients. The decline in oxycodone dispensing among chronic oxycodone recipients corresponded with an increase in dispensing of other opioid formulations, particularly hydromorphone and fentanyl. No important differences were observed for ED visits related to opioid poisoning, overdose, or substance use disorder.Province-wide restrictions on access to long acting oxycodone had an impact on quantities of all opioids dispensed to chronic recipients of oxycodone, but small impacts on the full population of people dispensed oxycodone; the decline in use was partially offset by increases in use of other publicly-funded opioid formulations. This study suggests that policies limiting access to specific prescription opioids led to overall reductions in publicly funded prescription opioid use, particularly in chronic oxycodone recipients, without immediate evidence of changes in opioid-related ED visits.

Emergency department visits for a psychiatric reason in the post-partum period represent an acute need for mental health care at a crucial time, but little is known about the extent of timely outpatient follow-up after these visits or how individual and intersecting social determinants of health influence this outcome. This study aimed to examine outpatient mental health care follow-up by a physician in the 30 days after an individual attended the emergency department for a psychiatric reason in the post-partum period and understand how social determinants of health affect who receives follow-up care.In this population-based cohort study, routinely collected health data from Ontario, Canada were accessed through ICES to identify all post-partum individuals whose sex was listed as female on their health card and who had attended an emergency department in Ontario before the COVID-19 pandemic for a psychiatric reason. Individuals admitted to hospital at the time of the emergency department visit, who died during the visit, or who left without being seen were excluded from the study. Ethnicity data for individuals were not collected. The primary outcome was the proportion of individuals with any outpatient physician (psychiatrist or family physician) visit for a mental health reason within 30 days of the index emergency department visit. Family physician mental health visits were identified using a validated algorithm for Ontario Health Insurance Plan-billed visits and mental health diagnostic codes for community health centre visits. We examined the associations between social determinants of health (age, neighbourhood income, community size, immigration, neighbourhood ethnic diversity) and who received an outpatient mental health visit. We used modified Poisson regression adjusting for the other social determinants of health, clinical, and health services characteristics to examine independent associations with follow-up, and conditional inference trees to explore how social determinants of health intersect with each other and with clinical and health services characteristics in relation to follow-up.We analysed data collected between April 1, 2008, and March 10, 2020, after exclusions we identified 12 158 people who had attended the emergency department for a psychiatric reason in the post-partum period (mean age 26·9 years [SD 6·2]; range 13-47); 9848 individuals lived in an urban area, among these 1518 (15·5%) were immigrants and 2587 (26·3%) lived in areas with high ethnic diversity. 5442 (44·8%) of 12 158 individuals received 30-day follow-up. In modified Poisson regression models, younger age, lower neighbourhood income, smaller community size, and being an immigrant were associated with a lower likelihood of follow-up. In the CTREE, similar variables were important, with several intersections between social determinants of health and between social determinants of health and other variables.Fewer than half of emergency department visits for a psychiatric reason in the post-partum period were followed by timely outpatient care, with social-determinants-of-health-based disparities in access to care. Improvements in equitable access to post-emergency department mental health care are urgently needed in this high-risk post-partum population.Department of Psychiatry, University of Toronto; Canadian Institutes of Health Research.

Background Patients diagnosed with cancer often experience considerable challenges with mental health, and those who had more intense psychiatric care prior to their cancer diagnosis have a higher risk of mortality. As prior research demonstrated a survival benefit among patients screened for symptoms using the Edmonton symptom assessment system (ESAS), this study aims to examine the association between being ESAS‐screened and the risk of mortality across varying intensity levels of pre‐diagnosis psychiatric care utilization. Methods We conducted a retrospective matched cohort study using population‐wide administrative databases. All patients diagnosed with cancer in Ontario, Canada, from January 2007 to December 2015 were identified. Propensity score matching was used to pair ESAS‐screened individuals to those not screened. Pairs were also hard matched on a pre‐diagnosis psychiatric care utilization gradient. A multivariable Cox proportional hazards regression model was implemented to estimate the association between ESAS and mortality, for each intensity level of pre‐diagnosis psychiatric care. Results The matched cohort consisted of 119,806 patient pairs (ESAS‐screened and not screened), of whom 54,468 (45.5%) pairs had prior outpatient psychiatric care and 2249 (1.8%) pairs had experienced emergency department visits or had been hospitalized for psychiatric care. Overall being exposed to ESAS was significantly associated with a 51% decrease in the hazard of mortality (HR 0.49, 95%CI 0.48–0.50, p‐value

LAY SUMMARY This study tried to answer the question “Do children and youth in military families have a greater risk of emotional and behavioural problems than children and youth in the general population?” The authors used routinely collected health data from children and youth in Canadian Armed Forces families who relocated to Ontario, matched to data from children and youth in non-military families. They compared outpatient mental health services use, such as physician visits, and the reasons for those visits, such as depression. They found that children and youth in military families were more likely to visit a physician for specific mental health diagnoses than children and youth in the general population. More programming and resources supporting the mental health and well-being of children and youth in military families may be needed.

Background: Benzodiazepine treatment recommendations for older adults differ markedly between guidelines, especially their advice on the acceptability of long-term use. Aims: Using population-based data we compared risks associated with chronic versus intermittent benzodiazepine usage in older adults. The primary outcome was falls resulting in hospital/emergency department visits. Methods: We undertook a retrospective population-based cohort study using linked healthcare databases in adults aged ⩾ 66 years in Ontario, Canada, with a first prescription for benzodiazepines. Chronic and intermittent benzodiazepine users, based on the 180 days from index prescription, were matched (1:2 ratio) by sex, age and propensity score, then followed for up to 360 days. Hazard ratios (HRs) for outcomes were calculated from Cox regression models. Results: A total of 57,041 chronic and 113,839 matched intermittent users were included. Hospitalization/emergency department visits for falls occurred during follow up in 4.6% chronic versus 3.2% intermittent users (HR = 1.13, 95% confidence interval (CI): 1.08 to 1.19; p Conclusion: Our study demonstrates evidence of significant excess risks associated with chronic benzodiazepine use compared to intermittent use. The excess risks may inform decision-making by older adults and clinicians about whether short- or long-term benzodiazepine use is a reasonable option for symptom management.

Cannabis-related emergency department visits can be an entry point for youths to mental health and substance use care systems. We aimed to examine trends in cannabis-related emergency department visits as a function of youths' age and sex.Using administrative data, we examined all visits to emergency departments in Ontario, Canada, from 2003 to 2017, by youth aged 10-24 years (grouped as 10-13, 14-18 and 19-24 yr) to determine trends in cannabis-related emergency department visits. Cannabis-related visits were identified usingWe examined 14 697 778 emergency department visits. Cannabis-related visits increased from 3.8 per 10 000 youths (95% confidence interval [CI] 3.5-4.0) in 2003 to 17.9 (95% CI 17.4-18.4) in 2017, a 4.8-fold increase (95% CI 4.4-5.1). Rates increased for both sexes and each age group. Males were more likely to have a visit than females (rate ratios ≥ 1.5 in 2003 and 2017). The number of cannabis-related visits in 2017 was 25.0 per 10 000 (95% CI 24.0-25.9) among youth aged 19-24 years, 21.9 per 10 000 (95% CI 20.9-22.9) among those aged 14-18 years, and 0.8 per 10 000 (95% CI 0.5-1.0) among those aged 10-13 years. In 2017, 88.2% (95% CI 87.3%-89.0%) of cannabis-related visits and 58.1% (95% CI 58.0%-58.2%) of non-cannabis-related visits were triaged as "more severe," (rate ratio 1.52, 95% CI 1.50-1.53). Similarly, in 2017, 19.0% (95% CI 18.0%-20.1%) of cannabis-related visits and 5.8% (95% CI 5.7%-5.8%) of non-cannabis-related visits resulted in hospital admission (rate ratio 3.3, 95% CI 3.1-3.5).Rates of cannabis-related emergency department visit by youths aged 10-24 years increased almost fivefold from 2003 to 2017, with increases in visit severity and hospital admissions. These trends describe an emerging public health problem, and research is needed to identify the causes of this increase and the health and social consequences of cannabis-related visits for these youths.

Objective: To determine whether the release of the first season of the Netflix series ‘13 Reasons Why’ was associated with changes in emergency department presentations for self-harm. Methods: Healthcare utilization databases were used to identify emergency department and outpatient presentations according to age and sex for residents of Ontario, Canada. Data from 2007 to 2018 were used in autoregressive integrated moving average models for time series forecasting with a pre-specified hypothesis that rates of emergency department presentations for self-harm would increase in the 3-month period following the release of 13 Reasons Why (1 April 2017 to 30 June 2017). Chi-square and t tests were used to identify demographic and health service use differences between those presenting to emergency department with self-harm during this epoch compared to a control period (1 April 2016 to 30 June 2016). Results: There was a significant estimated excess of 75 self-harm-related emergency department visits (+6.4%) in the 3 months after 13 Reasons Why above what was predicted by the autoregressive integrated moving average model (standard error = 32.4; p = 0.02); adolescents aged 10–19 years had 60 excess visits (standard error = 30.7; p = 0.048), whereas adults demonstrated no significant change. Sex-stratified analyses demonstrated that these findings were largely driven by significant increases in females. There were no differences in demographic or health service use characteristics between those who presented to emergency department with self-harm in April to June 2017 vs April to June 2016. Conclusions: This study demonstrated a significant increase in self-harm emergency department visits associated with the release of 13 Reasons Why. It adds to previously published mortality, survey and helpline data collectively demonstrating negative mental health outcomes associated with 13 Reasons Why.

Objective This study aims to examine rural and urban differences in attempted suicide and death by suicide in Ontario, Canada. Method This is a population-based nested case-control study. Data were obtained from administrative databases held at ICES, which capture all hospital and emergency department visits across Ontario between 2007 and 2017. All adults living in Ontario who attempted suicide or died by suicide are included in the study, and controls were matched by sex and age. Suicides were captured using vital statistics. Suicide attempts were determined using emergency department service codes. Results Rurality is a risk factor for attempted suicide and death by suicide. Rural males are more likely to die by suicide compared with urban males (adjusted odds ratio(AOR) = 1.70, 95% confidence interval (CI), 1.49 to 1.95), and the odds of death by suicide increase with increasing levels of rurality. Rural males and females have an increased risk of attempted suicide compared with their urban counterparts (males: AOR = 1.37, 95% CI, 1.24 to 1.50) (females: AOR = 1.26, 95% CI, 1.14 to 1.39), with a pattern of increasing risk of suicide attempts with increasing rurality. Rural females are not at increased risk of suicide compared with urban females (AOR = 1.08, 95% CI, 0.80 to 1.45). Sensitivity analyses corroborated the results. Conclusions Rural males are almost two times more likely to die by suicide compared with urban males, and both rural males and females have an elevated risk of suicide attempts compared with urban residents. Future research should examine potential mediators of the relationship between rurality and suicide.

Objective Individuals with mental illness and addiction are overrepresented in prisons. Few studies have assessed mental health and addiction (MHA)-related service use among individuals experiencing incarceration using health administrative data and most focus on service use after prison release. The objective of this study was to determine the prevalence of MHA-related service use in the 5 years prior to and during incarceration. Methods We used linked correctional and administrative health data for people released from Ontario provincial jails in 2010. MHA-related service use in the 5 years prior to the index incarceration was categorized hierarchically into four mutually exclusive categories based on the type of service use: psychiatric hospitalization, MHA-related emergency department (ED) visit, MHA-related outpatient visit (from psychiatrist or primary care physician), and no MHA-related service use. Demographic, diagnostic, and incarceration characteristics were compared across the four service use categories. MHA-related service use during the index incarceration was assessed by category and length of incarceration. Results A total of 48,917 individuals were included. Prior to incarceration, 6,116 (12.5%) had a psychiatric hospitalization, 8,837 (18.1%) had an MHA-related ED visit, and 15,866 (32.4%) had an MHA-related outpatient visit. Of the individuals with any MHA-related service prior to incarceration, 60.4% did not receive outpatient care from a psychiatrist prior to incarceration and 65.6% did not receive MHA-related care during incarceration. Conclusion Despite a high prevalence of mental illness and addiction among people experiencing incarceration, access to and use of MHA-related care prior to and during incarceration is poor. Increasing the accessibility and use of MHA-related services throughout the criminal justice pathway is warranted.

Background There is mixed evidence on the link between mental health and addiction (MHA) history and recidivism. Few studies have examined post-release MHA care. Our objective was to examine the association between prior (pre-incarceration) MHA service use and post-release recidivism and service use. Methods We conducted a population-based cohort study linking individuals held in provincial correctional institutions in 2010 to health administrative databases. Prior MHA service use was assigned hierarchically in order of hospitalization, emergency department visit and outpatient visit. We followed up individuals post-release for up to 5 years for the first occurrence of recidivism and MHA hospitalization, emergency department visit and outpatient visit. We use Cox-proportional hazards models to examine the association between prior MHA service use and each outcome adjusting for prior correctional involvement and demographic characteristics. Results Among a sample consisting of 45,890 individuals, we found that prior MHA service use was moderately associated with recidivism (hazard ratio (HR): 1.20–1.50, all P Discussion Despite a high risk of recidivism and acute MHA utilization post-release, we found low access to MHA outpatient care, highlighting the necessity for greater efforts to facilitate access to care and care integration for individuals with mental health needs in correctional facilities.

Background The extent to which heightened distress during the COVID-19 pandemic translated to increases in severe mental health outcomes is unknown. We examined trends in psychiatric presentations to acute care settings in the first 12 months after onset of the pandemic. Methods This was a trends analysis of administrative population data in Ontario, Canada. We examined rates of hospitalizations and emergency department visits for mental health diagnoses overall and stratified by sex, age and diagnostic grouping (e.g., mood disorders, anxiety disorders, psychotic disorders), as well as visits for intentional self-injury for people aged 10 to 105 years, from January 2019 to March 2021. We used Joinpoint regression to identify significant inflection points after the onset of the pandemic in March 2020. Results Among the 12 968 100 people included in our analysis, rates of mental health-related hospitalizations and emergency department visits declined immediately after the onset of the pandemic (peak overall decline of 30% [hospitalizations] and 37% [emergency department visits] compared to April 2019) and returned to near prepandemic levels by March 2021. Compared to April 2019, visits for intentional self-injury declined by 33% and remained below prepandemic levels until March 2021. We observed the largest declines in service use among adolescents aged 14 to 17 years (55% decline in hospitalizations, 58% decline in emergency department visits) and 10 to 13 years (56% decline in self-injury), and for those with substance-related disorders (33% decline in emergency department visits) and anxiety disorders (61% decline in hospitalizations). Interpretation Contrary to expectations, the abrupt decline in acute mental health service use immediately after the onset of the pandemic and the return to near prepandemic levels that we observed suggest that changes and stressors in the first 12 months of the pandemic did not translate to increased service use. Continued surveillance of acute mental health service use is warranted.

Objective To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization. Method Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1–18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization. Results In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P Conclusions Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

Primary care physicians play a central role in pathways to care for first-episode psychosis, and their increased involvement in early detection could improve service-related outcomes. The aim of this study was to estimate the proportion of psychosis first diagnosed in primary care, and identify associated patient and physician factors. We used linked health administrative data to construct a retrospective cohort of people aged 14-35 years with a first diagnosis of non-affective psychosis in Ontario, Canada between 2005-2015. We restricted the sample to patients with help-seeking contacts for mental health reasons in primary care in the six months prior to first diagnosis of psychotic disorder. We used modified Poisson regression models to examine patient and physician factors associated with a first diagnosis of psychosis in primary care. Among people with early psychosis (n = 39,449), 63% had help-seeking contacts in primary care within six months prior to first diagnosis. Of those patients, 47% were diagnosed in primary care and 53% in secondary/tertiary care. Patients factors associated with lower likelihood of diagnosis in primary care included male sex, younger age, immigrant status, and comorbid psychosocial conditions. Physician factors associated with lower likelihood of diagnosis in primary care included solo practice model, urban practice setting, international medical education, and longer time since graduation. Our findings indicate that primary care is an important contact for help-seeking and diagnosis for a large proportion of people with early psychosis. For physicians less likely to diagnose psychosis in primary care, targeted resources and interventions could be provided to support them in caring for patients with early psychosis.

ImportanceRetention in buprenorphine therapy is associated with a lower risk of opioid overdose. Nevertheless, many patients discontinue treatment, and there is limited evidence to guide buprenorphine tapering.ObjectiveTo understand what prescribing characteristics are associated with opioid overdose following buprenorphine taper.Design, Setting, and ParticipantsThis is a population-based, retrospective, cohort study of adults who were maintained on buprenorphine for at least 60 days and underwent a buprenorphine taper. The study was conducted in the Canadian province of Ontario, using linked administrative health data. New buprenorphine treatment episodes were accrued between January 1, 2013, and January 1, 2019, and the maximum follow-up was April 30, 2020. Data analysis was performed from December 2020 to August 2022.ExposuresThe primary exposure of interest was time to taper initiation (≤1 year vs >1 year). Secondary exposures included mean rate of taper, percentage days during which the dose was decreasing, and taper duration.Main Outcomes and MeasuresThe primary outcome measure was time to fatal or nonfatal opioid overdose within 18 months following treatment discontinuation.ResultsAmong 5774 individuals, the median (IQR) age at index date was 34 (28-44) years, and 3462 individuals (60.0%) were male. Time to taper initiation longer than 1 year vs 1 year or less (6.73 vs 10.35 overdoses per 100 person-years; adjusted hazard ratio [aHR], 0.69; 95% CI, 0.48-0.997), a lower mean rate of taper (≤2 mg per month, 6.95 overdoses per 100 person-years; >2 to ≤4 mg per month, 11.48 overdoses per 100 person-years; >4 mg per month, 17.27 overdoses per 100 person-years; ≤2 mg per month vs >4 mg per month, aHR, 0.65; 95% CI, 0.46-0.91; >2 to ≤4 mg per month vs >4 mg per month, aHR, 0.69; 95% CI, 0.51-0.93), and dose decreases in 1.75% or less of days vs more than 3.50% of days during the taper period (5.87 vs 13.87 overdoses per 100 person-years; aHR, 0.64; 95% CI, 0.43-0.93) were associated with reduced risk of opioid overdose; however, taper duration was not.Conclusions and RelevanceIn this retrospective cohort study, buprenorphine tapers undertaken after at least 1 year of therapy, a slower rate of taper, and a lower percentage of days during which the dose was decreasing were associated with a significantly lower risk of opioid overdose, regardless of taper duration. These findings underscore the importance of a carefully planned taper and could contribute to reduction in opioid-related overdose death.

Background Occupational exposures may result in Canadian military Veterans having poorer health and higher use of health services after transitioning to civilian life compared to the general population. However, few studies have documented the physical health and health services use of Veterans in Canada, and thus there is limited evidence to inform public health policy and resource allocation. Methods In a retrospective, matched cohort of Veterans and the Ontario general population between 1990–2019, we used routinely collected provincial administrative health data to examine chronic disease prevalence and health service use. Veterans were defined as former members of the Canadian Armed Forces or RCMP. Crude and adjusted effect estimates, and 95% confidence limits were calculated using logistic regression (asthma, COPD, diabetes, myocardial infarction, rheumatoid arthritis, family physician, specialist, emergency department, and home care visits, as well as hospitalizations). Modified Poisson was used to estimate relative differences in the prevalence of hypertension. Poisson regression compares rates of health services use between the two groups. Results The study included 30,576 Veterans and 122,293 matched civilians. In the first five years after transition to civilian life, Veterans were less likely than the general population to experience asthma (RR 0.50, 95% CI 0.48–0.53), COPD (RR 0.32, 95% CI 0.29–0.36), hypertension (RR 0.74, 95% CI 0.71–0.76), diabetes (RR 0.71, 95% CI 0.67–0.76), myocardial infarction (RR 0.76, 95% CI 0.63–0.92), and rheumatoid arthritis (RR 0.74, 95% CI 0.60–0.92). Compared to the general population, Veterans had greater odds of visiting a primary care physician (OR 1.76, 95% CI 1.70–1.83) or specialist physician (OR 1.39, 95% CI 1.35–1.42) at least once in the five-year period and lower odds of visiting the emergency department (OR 0.95, 95% CI 0.92–0.97). Risks of hospitalization and of receiving home care services were similar in both groups. Conclusions Despite a lower burden of comorbidities, Veterans had slightly higher physician visit rates. While these visits may reflect an underlying need for services, our findings suggest that Canadian Veterans have good access to primary and specialty health care. But in light of contradictory findings in other jurisdictions, the underlying reasons for our findings warrant further study.

ImportanceResearch on patients with high health care costs has examined mainly adults, with little focus on mental health care use.ObjectiveTo examine the characteristics and costs of children and adolescents with high health care costs who use mostly mental health care and whether and why they persist in the high-cost state.Design, Setting, and ParticipantsThis population-based, retrospective cohort study used health care records from Ontario, Canada, on all children and adolescents (age 0-17 years) covered under a universal health care system from January 1, 2012, to December 31, 2019. All children and adolescents in and above the 90th percentile of the cost distribution in 2012 for whom costs related to mental health care accounted for 50% or more of their costs were defined as patients with high mental health care costs. Data were analyzed from August 2019 to December 2022.ExposuresHigh health care costs.Main Outcomes and MeasuresPatients with high mental health care costs were characterized in terms of their sociodemographic characteristics; chronic physical health, mental health, and behavioral conditions; and health care costs (in 2021 Canadian dollars) by health service and type of care (mental health care vs non–mental health care). Patients were followed up until 2019 to assess whether they persisted in the high-cost state and to examine factors associated with persisting in that state.ResultsIn 2012, there were 273 490 children and adolescents with high health care costs (mean [SD] age, 6.43 [5.99] years; 55.8% male; mean cost, $7936.40; 95% CI, $7850.30-$8022.40). Of these, 20 463 (7.5%) were classified as having high mental health care costs (mean cost, $10 040.20; 95% CI, $9822.80-$10 257.50). Asthma (30.3%), attention-deficit/hyperactivity disorder (35.8%), and mood and/or anxiety disorders (94.9%) were the most common chronic physical, behavioral, or mental health conditions. Few patients with high mental health care costs persisted in the high-cost state beyond 3 years (19.0%). Mood and/or anxiety disorders (relative risk ratio [RRR], 6.17; 95% CI, 3.19-11.96) and schizophrenia spectrum disorders (RRR, 2.98; 95% CI, 2.14-4.14) were identified as the main factors associated with persistence in the high-cost state.Conclusions and RelevanceIn this cohort study of children and adolescents with high health care costs, some patients had high levels of mental health care use and high costs of care, but few of these persisted in the high-cost state for 3 or more years. These findings may help inform the development of care coordination interventions and service delivery models, such as youth integrated services, to reduce costs and improve outcomes for children and adolescents.

Objectives To determine if and to what degree neighbourhood-level marginalization mediates mental health service use among transgender individuals. Methods This retrospective cohort study identified 2,085 transgender individuals through data obtained from 4 outpatient community and hospital clinics in 3 large cities in Ontario, which were linked with administrative health data between January 2015 and December 2019. An age-matched 1:5 comparison cohort was created from the general population of Ontario. Outcome measures were analysed from March 2020 to May 2022. The primary outcome was mental health service utilization, which included mental health-related visits to primary care providers, psychiatrists, mental health- and self-harm-related emergency department visits, and mental health hospitalizations. Mediation variables included ethnic concentration, residential instability, dependency, and material deprivation at the neighbourhood level and were derived from the Ontario Marginalization Index. Results This study identified 2,085 transgender individuals from participating outpatient community and hospital clinics, who were matched to the general population ( n = 10,425). Overall, neighbourhood-level marginalization did not clinically mediate mental health service use. However, transgender individuals were more likely to be exposed to all forms of neighbourhood-level marginalization, as well as having higher rates of health service use across all outcome measures. Conclusions In this study, mental health service use among transgender individuals was not clinically mediated by marginalization at the neighbourhood level. This study highlights the need to explore marginalization and mental health service use at the individual level to better understand the mental health disparities experienced by transgender individuals and to ensure that health-care services are inclusive and affirming.

The spouses of military members experience frequent geographic mobility, absences, risk, and other lifestyle dimensions that may cause a greater need for mental health services and barriers to thei...

BackgroundNo research has assessed the individual-level impact of smoking cessation treatment delivered within a general primary care patient population on multiple forms of subsequent healthcare service use.ObjectiveWe aimed to compare the rate of outpatient visits, emergency department (ED) visits and hospitalisations during a 5-year follow-up period among smokers who had and had not accessed a smoking cessation treatment programme.MethodsThe study was a retrospective matched cohort study using linked demographic and administrative healthcare databases in Ontario, Canada. 9951 patients who accessed smoking cessation services between July 2011 and December 2012 were matched to a smoker who did not access services, obtained from the Canadian Community Health Survey, using a combination of hard matching and propensity score matching. Outcomes were rates of healthcare service use from index date (programme enrolment or survey response) to March 2017.ResultsAfter controlling for potential confounders, patients in the overall treatment cohort had modestly greater rates of the outcomes: outpatient visits (rate ratio (RR) 1.10, 95% CI: 1.06 to 1.14), ED visits (RR 1.08, 95% CI: 1.03 to 1.13) and hospitalisations (RR 1.09, 95% CI: 1.02 to 1.18). Effect modification of the association between smoking cessation treatment and healthcare service use by prevalent comorbidity was found for outpatient visits (p=0.006), and hospitalisations (p=0.050), but not ED visits.ConclusionsPatients who enrolled in smoking cessation treatment offered through primary care clinics in Ontario displayed a modest but significantly greater rate of outpatient visits, ED visits and hospitalisations over a 5-year follow-up period.

PURPOSE Risk and predictors of long-term mental health outcomes in survivors of adolescent and young adult (AYA) cancers are poorly characterized. Mental health is consequently neglected in long-term follow-up. METHODS We identified all AYA in Ontario, Canada age 15-21 years when diagnosed with one of six common cancers between 1992-2012 using a population-based database, and compared them with matched controls. Linkage to provincial healthcare data allowed analysis of rates of outpatient (family physician and psychiatrist) visits for psychiatric indications and time to severe psychiatric events (emergency room visit, hospitalization, and suicide). Demographic-, disease-, and treatment-related predictors of adverse outcomes, including treatment setting (adult v pediatric), were examined. RESULTS Among 2,208 survivors and 10,457 matched controls, 5-year survivors experienced higher rates of outpatient mental health visits than controls (671 visits per 1,000 person-years v 506; adjusted rate ratio [RR] 1.3; 95% CI, 1.1 to 1.5; P = .006). Risk of a severe psychiatric episode was also increased among survivors (adjusted hazard ratio [HR], 1.2; 95% CI, 1.1 to 1.4, P = .008). Risk of a psychotic disorder–associated severe event was doubled in survivors (HR, 2.0, 95% CI, 1.3 to 2.4; P = .007) although absolute risk remained low (15-year cumulative incidence 1.7%; 95% CI, 1.0 to 2.7). In multivariable analysis, survivors treated in adult centers experienced substantially higher outpatient visit rates compared with those treated in pediatric settings (RR 1.8; 95% CI, 1.0 to 3.1; P = .04). CONCLUSION Survivors of AYA cancer are at substantially increased risk of adverse mental health outcomes, with those treated in adult centers at particular risk. Although absolute incidence was low, survivors were at increased risk of psychotic disorder–associated severe events. Long-term mental health surveillance is warranted, as is research into effective interventions during or after cancer treatment.

ImportanceEvidence suggests that individuals with schizophrenia are at an increased risk of hip fractures; however, the sex-specific burden of hip fractures among adults with schizophrenia has not been quantified and compared with the general population.ObjectiveTo describe sociodemographic and clinical characteristics of patients with hip fracture and schizophrenia and to quantify their sex-specific annual hip fracture rates relative to those without schizophrenia.Design, Setting, and ParticipantsThis repeated population-based, cross-sectional study leveraged multiple individually linked health administrative databases for patients in Ontario, Canada. We included patients aged 40 to 105 years with hip fracture–related hospitalization between April 1, 2009, and March 31, 2019. Statistical analysis was performed between November 2021 and February 2023.ExposureSchizophrenia diagnosis, ascertained using a validated algorithm.Main Outcomes and MeasuresThe main outcome was sex-specific age-standardized annual hip fracture rate per 10 000 individuals and annual percent change in age-standardized rates. Rates were direct adjusted to the 2011 Ontario population, and joinpoint regression analysis was performed to evaluate annual percent change.ResultsWe identified 117 431 hip fracture records; of these, there were 109 908 index events. Among the 109 908 patients with hip fracture, 4251 had schizophrenia and 105 657 did not. Their median age was 83 years (IQR, 75-89 years), and 34 500 (31.4%) were men. Patients with hip fracture and schizophrenia were younger at the index event compared with those without schizophrenia. Men had a median age of 73 vs 81 years (IQR, 62-83 vs 71-87 years; standardized difference, 0.46), and women had a median age of 80 vs 84 years (IQR, 71-87 vs 77-89 years; standardized difference, 0.32). A higher proportion of patients with vs without schizophrenia had frailty (53.7% vs 34.2%; standardized difference, 0.40) and previous fragility fractures (23.5% vs 19.1%; standardized difference, 0.11). The overall age-standardized rate per 10 000 individuals with vs without schizophrenia was 37.5 (95% CI, 36.4 to 38.6) vs 16.0 (95% CI, 15.9 to 16.1). Age-standardized rates were 3-fold higher in men with vs without schizophrenia (31.0 [95% CI, 29.5 to 32.6] vs 10.1 [95% CI, 10.0 to 10.2]) and more than 2-fold higher in women with vs without schizophrenia (43.4 [95% CI, 41.9 to 44.9] vs 21.4 [95% CI, 21.3 to 21.6]). Overall, joinpoint regression analysis identified a steady annual decrease of 0.7% (95% CI, −1.1% to −0.3%) in age-standardized rates for both study groups.Conclusions and RelevanceThe findings of this cross-sectional study suggest that individuals with schizophrenia experience an earlier age of onset and considerably higher rate of hip fractures compared with the general population, with implications for targeted fracture prevention and optimization of clinical bone health management over the course of their psychiatric illness.

Objective To examine the association between Muslim religious affiliation and suicide and self-harm presentations among first- and second-generation immigrant youth. Methods We performed a population-based cohort study involving individuals aged 12 to 24 years, living in Ontario, who immigrated to Canada between 1 January 2003 and 31 May 2017 (first generation) and those born to immigrant mothers (second generation). Health administrative and demographic data were used to analyze suicide and self-harm presentations. Sex-stratified logistic regression models generated odds ratios (OR) for suicide and negative binomial regression models generated rate ratios (aRR) for self-harm presentations, adjusting for refugee status and time since migration. Results Of 1,070,248 immigrant youth (50.1% female), there were 129,919 (23.8%) females and 129,446 (24.2%) males from Muslim-majority countries. Males from Muslim-majority countries had lower suicide rates (3.8/100,000 person years [PY]) compared to males from Muslim-minority countries (5.9/100,000 PY) (OR: 0.62, 95% CI, 0.42–0.92). Rates of suicide between female Muslim-majority and Muslim-minority groups were not different (Muslim-majority 1.8/100,000 PY; Muslim-minority 2.2/100,000 PY) (OR: 0.82, 95% CI, 0.46–1.47). Males from Muslim-majority countries had lower rates of self-harm presentations than males from Muslim-minority (Conclusion Being a male from a Muslim-majority country may confer protection from suicide and self-harm presentations but the same was not observed for females. Approaches to understanding the observed sex-based differences are warranted.

Objective The impacts of the COVID-19 pandemic on psychiatric hospitalizations in Ontario are unknown. The purpose of this study was to identify changes to volumes and characteristics of psychiatric hospitalizations in Ontario during the COVID-19 pandemic. Methods A time series analysis was done using psychiatric hospitalizations with admissions dates from July 2017 to September 2021 identified from provincial health administrative data. Variables included monthly volumes of hospitalizations as well as proportions of stays Results A total of 236,634 psychiatric hospitalizations were identified. Volumes decreased in the first few months of the pandemic before returning to prepandemic volumes by May 2020. However, monthly hospitalizations for psychotic disorders increased by ∼9% compared to the prepandemic period and remained elevated thereafter. Short stays and involuntary admissions increased by approximately 2% and 7%, respectively, before trending downwards. Conclusion Psychiatric hospitalizations quickly stabilized in response to the COVID-19 pandemic. However, evidence suggested a shift towards a more severe presentation during this period.

Objectives Despite unregulated amphetamine use increasing, there are limited data on related emergency department (ED) visits in Canada. Our primary objective was to examine trends in amphetamine-related ED visits over time in Ontario, including by age and sex. Secondary objectives were to examine whether patient characteristics were associated with ED revisit within 6 months. Methods Using administrative claims and census data, we calculated annual patient- and encounter-based rates of amphetamine-related ED visits from 2003 to 2020 among individuals 18+ years of age. We also performed a retrospective cohort study of individuals with amphetamine-related ED visits between 2019 and 2020 to determine whether select factors were associated with ED revisit within 6 months. Multivariable logistic regression modelling was used to measure associations. Results The population-based rate of amphetamine-related ED visits increased nearly 15-fold between 2003 (1.9/100,000 Ontarians) and 2020 (27.9/100,000 Ontarians). Seventy-five percent of individuals returned to the ED for any reason within 6 months. Psychosis and use of other substances were both independently associated with ED revisit for any reason within 6 months (psychosis: AOR = 1.54, 95% CI = 1.30–1.83; other substances: AOR = 1.84, 95% CI = 1.57–2.15), whereas having a primary care physician was negatively associated with ED revisit (AOR = 0.77, 95% CI = 0.60–0.98). Conclusions Increasing rates of amphetamine-related ED visits in Ontario are cause for concern. Diagnoses of psychosis and the use of other substances may serve to identify individuals who are most likely to benefit from both primary and substance-specific care.

Background Collaborative care (CC) could improve outcomes in primary care patients with common mental conditions. We assessed the effectiveness of a transdiagnostic model of telephone-based CC (tCC) delivered by lay providers to primary care patients with depression, anxiety, or at-risk drinking. Methods PARTNERS was a pragmatic trial in 502 primary care adults presenting with depressive symptoms, anxiety symptoms, or at-risk drinking randomized to (1) usual care by primary care providers (PCPs) enhanced with the results of computer-assisted telephone-based assessments (at baseline and 4, 8, and 12 months later) (enhanced usual care [eUC]) or (2) tCC consisting of eUC plus frequent telephone coaching and psychoeducation provided by mental health technicians who also communicated to the PCP recommendations from a psychiatrist for evidence-based pharmacotherapy, psychotherapy, or, when indicated, referrals to mental health services. The primary analysis compared the change on the 9-item Patient Health Questionnaire (PHQ-9) in participants presenting with depression ( n = 366) randomized to tCC versus eUC. Secondary analyses compared changes on the Generalized Anxiety Disorder-7 scale (GAD-7) in those presenting with anxiety ( n = 298); or change in the number of weekly drinks in those presenting with at-risk drinking ( n = 176). Results There were no treatment or time×treatment effects between tCC and eUC on PHQ-9 scores for patients with depression during the 12-month follow-up. However, there was a treatment effect (tCC > eUC) on GAD-7 scores in those with anxiety and a time×treatment interaction effect on the number of weekly drinks (tCC > eUC) in those with at-risk drinking. Conclusion Implementing transdiagnostic tCC for common mental disorders using lay providers appears feasible in Canadian primary care. While tCC was not better than eUC for depression, there were some benefits for those with anxiety or at-risk drinking. Future studies will need to confirm whether tCC differentially benefits patients with depression, anxiety, or at-risk drinking.

Objective We sought to evaluate the relationship between social determinants of health and physician-based mental healthcare utilization and virtual care use among children and adolescents in Ontario, Canada, during the COVID-19 pandemic. Methods This population-based repeated cross-sectional study of children and adolescents (3–17 years; N = 2.5 million) used linked health and demographic administrative data in Ontario, Canada (2017–2021). Multivariable Poisson regressions with generalized estimating equations compared rates of outpatient physician-based mental healthcare use during the first year of the COVID-19 pandemic with expected rates based on pre-COVID patterns. Analyses were conducted by socioeconomic status (material deprivation quintiles of the Ontario Marginalization index), urban/rural region of residence, and immigration status. Results Overall, pediatric physician-based mental healthcare visits were 5% lower than expected (rate ratio [RR] = 0.95, 95% confidence interval [CI], 0.92 to 0.98) among those living in the most deprived areas in the first year of the pandemic, compared with the least deprived with 4% higher than expected rates (RR = 1.04, 95% CI, 1.02 to 1.06). There were no differences in overall observed and expected visit rates by region of residence. Immigrants had 14% to 26% higher visit rates compared with expected from July 2020 to February 2021, whereas refugees had similarly observed and expected rates. Virtual care use was approximately 65% among refugees, compared with 70% for all strata. Conclusion During the first year of the pandemic, pediatric physician-based mental healthcare utilization was higher among immigrants and lower than expected among those with lower socioeconomic status. Refugees had the lowest use of virtual care. Further work is needed to understand whether these differences reflect issues in access to care or the need to help inform ongoing pandemic recovery planning.

Objective: This study examines whether depression is associated with the development of physical illness and multimorbidity, after controlling for socioeconomic, behavioral, and other potential confounders. Methods: This is a retrospective cohort study in which adult respondents to three nationally representative population health surveys were linked to health administrative databases in Ontario, Canada, and followed for 10 years from survey index. Respondents with any of the study outcome conditions at baseline were excluded to create a final cohort of 29,838 participants. The main exposure of interest was depression, measured using the Composite International Diagnostic Interview–Short Form for Major Depression. We controlled for age, body mass index, marital status, immigrant status, annual household income, smoking, alcohol consumption, physical activity, health status, and having a regular doctor. The outcome measure was the development of physical illness over 10 years of follow-up, defined as 1 of 15 common chronic conditions using administrative data. Results: Among the 29,838 participants (15,259 [51%] female), 8% of females and 4% of males had depression at baseline. In this cohort with no comorbidities at baseline, even in the fully adjusted model, depression increased the risk of developing a first physical illness for females (hazard ratio [HR] 1.16; 95% CI, 1.07 to 1.26) and males (HR 1.20; 95% CI, 1.07 to 1.36) and increased the risk of developing a second physical illness for females (HR 1.16; 95% CI, 1.02 to 1.33) over 10 years of follow-up. Conclusions: For individuals with no prior comorbidities, depression is associated with a greater risk of developing subsequent physical illness and multimorbidity over time. Thus, depression identifies a population of people who may benefit from early identification, additional screening, and intervention. Further study needs to be done to determine whether interventions to manage and support people with depression can prevent or delay the increased risk of multimorbidity.

BACKGROUND: Little is known about the risk of death among people who visit emergency departments frequently for alcohol-related reasons, including whether mortality risk increases with increasing frequency of visits. Our primary objective was to describe the sociodemographic and clinical characteristics of this high-risk population and examine their 1-year overall mortality, premature mortality and cause of death as a function of emergency department visit frequency in Ontario, Canada. METHODS: We conducted a population-based retrospective cohort study using linked health administrative data (Jan. 1, 2010, to Dec. 31, 2016) in Ontario for people aged 16–105 years who made at least 2 emergency department visits for mental or behavioural disorders due to alcohol within 1 year. We subdivided the cohort based on visit frequency (2, 3 or 4, or ≥ 5). The primary outcome was 1-year mortality, adjusted for age, sex, income, rural residence and presence of comorbidities. We examined premature mortality using years of potential life lost (YPLL). RESULTS: Of the 25 813 people included in the cohort, 17 020 (65.9%) had 2 emergency department visits within 1 year, 5704 (22.1%) had 3 or 4 visits, and 3089 (12.0%) had 5 or more visits. Males, people aged 45–64 years, and those living in urban centres and lower-income neighbourhoods were more likely to have 3 or 4 visits, or 5 or more visits. The all-cause 1-year mortality rate was 5.4% overall, ranging from 4.7% among patients with 2 visits to 8.8% among those with 5 or more visits. Death due to external causes (e.g., suicide, accidents) was most common. The adjusted mortality rate was 38% higher for patients with 5 or more visits than for those with 2 visits (adjusted hazard ratio 1.38, 95% confidence interval 1.19–1.59). Among 25 298 people aged 16–74 years, this represented 30 607 YPLL. INTERPRETATION: We observed a high mortality rate among relatively young, mostly urban, lower-income people with frequent emergency department visits for alcohol-related reasons. These visits are opportunities for intervention in a high-risk population to reduce a substantial mortality burden.

Social determinants of health (SDoH) impact psychiatric conditions. Routinely collected health data are frequently used to evaluate important psychiatric clinical and health services outcomes. This study explored how key SDoH are used in psychiatric research employing routinely collected health data.A search was conducted in PubMed for English-language articles published in 2019 that used routinely collected health data to study psychiatric conditions. Studies (n = 19,513) were randomly ordered for title/abstract review; the first 150 meeting criteria progressed to full-text review. Three key SDoH categories were assessed: (1) gender and sex, (2) race and ethnicity, and (3) socioeconomic status. Within each category, data were extracted on how variables were included, defined, and used in study design and analysis.All studies (n = 103) reported on at least one of the key SDoH variables; 102 (99.0%) studies included a gender and/or sex variable, 30 (29.1%) included a race and/or ethnicity variable, and 55 (53.4%) included a socioeconomic status variable. No studies explicitly differentiated between gender and sex, and SDoH were often defined only as binary variables. SDoH were used to define the target population in 14 (13.6%) studies. Within analysis, SDoH were most often included as confounders (n = 65, 63.1%), exposures or predictors (n = 23, 22.3%), and effect modifiers (n = 14, 13.6%). Only 21 studies (20.4%) disaggregated results by SDoH and 7 (6.8%) considered intersections between SDoH.Results suggest improvements are needed in how key SDoH are used in routinely collected health data-based psychiatric research, to ensure relevance to diverse populations and improve equity-oriented research.

Occupational exposures related to military service may increase the risk of cancer for military Veterans, while high levels of fitness during service may decrease risk. However, few studies have compared this post-career cancer risk directly to the employed general population.This retrospective cohort study used linked administrative data. Canadian Armed Forces and Royal Canadian Mounted Police Veterans in Ontario, Canada were matched 1:4 on age, sex, geography, and community-level income to a group of non-Veterans most likely to have been employed during a period similar to the Veterans' military service. Cancer diagnoses were identified using the Ontario Cancer Registry.During the study period, 642 of 30 576 included Veterans (2.1%) and 3408 of the 122 293 matched general population cohort (2.8%) experienced at least one cancer diagnosis. The crude rate of cancer was 153.5 per 100 000 person-years among Veterans vs. 205.9 per 100 000 person-years for the general population cohort. After adjusting for rurality and matching variables, Veterans had an 27% lower risk of developing any cancer than their matched comparators [hazard ratio = 0.73 (95% CI: 0.67-0.80)]. Among specific cancer types, the risk of lung and colorectal cancer was significantly lower for Veterans relative to the general population cohort; the risk of breast and prostate cancer was similar.This study adds to the growing international evidence suggesting that risk of many cancers among Veterans is lower or similar to the general population. Further understanding of the complex relationships among occupational exposures, environmental factors, and lifestyle factors is needed.