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Objectives Our understanding of the contribution of new presentations versus pre-existing eating disorders during the COVID-19 pandemic is limited. This study aims to evaluate rates of emergency department (ED) visits and hospitalizations for eating disorders among adolescents and young adults (YA) new to care and those with pre-existing eating disorders during the pandemic. Approach We conducted a population-based cross-sectional study using linked health administrative data for Ontario residents aged 10-26 during the pre-pandemic (Jan. 1, 2017-Feb. 29, 2020) and pandemic periods (Mar. 1, 2020-Jun. 30, 2022). We used Poisson generalized estimating equations models to predict expected overall and monthly rates of eating disorder-related ED visits and hospitalizations among those with a new and pre-existing eating disorder. Results Compared with expected rates, ED visits increased during the pandemic among only adolescents with new eating disorders (adolescent RR 2.12, 95% CI [1.84,2.45]). Additionally, both adolescents and YA with pre-existing eating disorders experienced an increase in ED visits (RR 2.78, 95% CI [2.28, 3.38] and RR 1.52, 95% CI [1.25, 1.85], respectively). Similarly, hospitalizations for new presentations increased solely for adolescents (RR 1.48, 95% CI [1.34,1.64]), while hospitalizations for pre-existing eating disorders increased for both adolescents (RR 1.82, 95% CI [1.43,2.32]) and YA (RR 1.12, 95% CI [1.01,1.23]). Conclusions There was an increase in acute care visits for eating disorders during the pandemic, especially among adolescents and YA with pre-existing conditions. This differentiation is important in advancing our understanding of the pandemic's effects on adolescents and YA and the healthcare system receiving them.

Introduction Most substance use disorder (SUD) treatment occurs in community settings. Community-based SUD treatment information is rarely captured or utilized. The objective of this study was to examine the efficiency of a data linkage of community-based SUD treatment to health administrative data holdings in Ontario, Canada, and to describe sociodemographic and clinical characteristics of individuals accessing SUD services. Methods Data from community-based SUD service providers (>180) from April 2015 to March 2022 were linked to administrative data holdings at ICES. Linkage rates were evaluated. Sociodemographic (age, sex, neighbourhood-level income) and clinical (substance use, physician visits, Emergency Department (ED) visits and hospitalizations) characteristics were evaluated. Results The linkage rate of DATIS ICES data holdings was >92% for all years (2015-2022). Of the 234,501 individuals admitted to a DATIS program, 36.1% were female, 46.2% were 25-44 years old, and 51.6% resided in the two lowest neighbourhood income quintiles. Alcohol (33.4%) was the most common substance identified. For outpatient care occurring within 1 year prior to admission, around 56.0% and 23.3% had Mental Health and Addictions (MHA) related primary care and psychiatrist visits, respectively. For acute health services, 29.8% and 14.2% had a MHA- related ED visit or hospitalization, respectively. Discussion SUD treatment data from community settings can be successfully linked to other health administrative data. Individuals with SUD have a high rate of acute health care use, and a relatively low access to psychiatrists. SUD treatment data linkage should be used to understand how to optimize access to care for vulnerable individuals.

Background Psychiatric conditions are common amongst hospitalized children. Co-occurring psychiatric conditions for medical hospitalizations contribute to length of stay, costs, and readmissions. We sought to measure trends over 20 years in pediatric hospitalizations for co-occurring medical and psychiatric conditions and compare with those without psychiatric comorbidity, overall and in free-standing children’s hospitals. Methods We identified all 3- to 17-year-olds hospitalized in Ontario, Canada between April 1, 2003 and March 31, 2022. Using health record discharge diagnoses, hospitalizations were assigned to 1 of 4 groups: 1) medical-diagnosis-only, 2) psychiatric-diagnosis-only, 3) primary medical diagnosis with psychiatric comorbidity, and 4) primary psychiatric diagnosis with medical comorbidity. Hospitalization trends for 1) all hospitals, and 2) free-standing children’s hospitals were described and compared. Results From 2003 to 2022, medical-diagnosis-only hospitalizations declined 39% (41,909 to 25,486 hospitalizations), psychiatric-diagnosis-only hospitalizations increased 96% (3227 to 6337), medical hospitalizations with psychiatric comorbidity increased 127% (977 to 2221) and psychiatric hospitalizations with medical comorbidity increased 100% (2051 to 4096). Among pediatric hospitals, medical-diagnosis-only hospitalizations increased 23% (12,430 to 15,318), psychiatric-diagnosis-only hospitalizations increased 420% (271 to 1408), psychiatric hospitalizations with medical comorbidity increased 172% (539 to 1468) and medical hospitalizations with psychiatric comorbidity increased 235% (478 to 1599). Conclusions Hospitals have experienced large absolute and relative increases in volumes for psychiatric conditions both with and without co-occurring medical conditions, particularly among free-standing children’s hospitals. Healthcare provider training, hospital resourcing, and health system planning must consider how best to accommodate the increasing acute psychiatric care needs of hospitalized children and adolescents.

Summary: Background: Immigrants in high-income countries experienced inequities in COVID-19 severe outcomes. We examined hospitalization and death throughout the pandemic, and change during the vaccine era, in Ontario, Canada. Methods: We conducted a population-based study using linked immigration and health data, following two cohorts for 20 months from January 1, 2020 (pre-vaccine) and September 1, 2021 (vaccine era). We used multivariable Poisson generalized estimating equation regression to estimate adjusted rate ratios (aRR) with 95% confidence intervals (CI), accounting for age, sex and co-morbidities. We calculated age-standardized years of life lost (ASYRs) rates by immigrant category. Findings: Of 11,692,387 community-dwelling adults in the pre-vaccine era cohort and 11,878,304 community-dwelling adults in the vaccine era cohort, 21.6% and 21.4% of adults in each era respectively were immigrants. Females accounted for 57.9% and 57.8% of sponsored family, and 68.4% and 67.6% of economic caregivers, in each era respectively. Compared to other Ontarians in the pre-vaccine era cohort, hospitalization rates were highest for refugees (aRR [95% CI] 3.41 [3.39–3.44]) and caregivers (3.13 [3.07–3.18]), followed by sponsored family and other economic immigrants. Compared to other Ontarians, aRRs were highest for immigrants from Central America (5.00 [4.92–5.09]), parts of South Asia (3.95 [3.89–4.01]) and Jamaica (3.56 [3.51–3.61]) with East Asians having lower aRRs. Mortality aRRs were similar to hospitalization aRRs. In the vaccine era, all aRRs were attenuated and most were similar to or lower than other Ontarians, with refugees and a few regions maintaining higher rates. In the pre-vaccine era ASYRs were higher for all immigrant groups. ASYRs dropped in the vaccine era with only refugees continuing to have higher rates. Interpretation: Immigrants, particularly refugees, experienced greater premature mortality. aRRs for most immigrant groups dropped substantially after high vaccine coverage was achieved. Vaccine outreach and improvements in the social determinants of health are needed. Funding: Canadian Institutes of Health Research, Canada Research Chairs Program.

BACKGROUND: Suicide is a major public health concern worldwide, including in Canada. The onset of major mental illnesses occurs during adolescence and young adulthood. Among this group, young Muslims in Canada may be particularly vulnerable due to unique stressors and emerging evidence indicating that Muslims in the U.S. report more suicide attempts than other religious groups. To our knowledge, no prior study has undertaken an in-depth exploration of the lived experiences of Muslim young adults who have attempted suicide. This study aims to broaden our understanding of how Muslim young adults experience and understand suicidal behavior by exploring narratives of distress and help-seeking, the meanings of suicidal behavior, the impact of immigration/resettlement, discrimination, Islamophobia, and the role of negotiating multiple religious, cultural, and gender identities. METHODS: This study is currently in progress. We are recruiting approximately 25-30 Muslim youth between the ages of 15-24 who have experienced suicidal behavior with any intent to die, as reported by the participants themselves, within the Greater Toronto Area (GTA). Exclusion criteria include (1) active substance intoxication or withdrawal, (2) current admission to a psychiatric facility, and (3) low levels of intellectual functioning or a history of neurological impairment. We are conducting heterogeneous purposive sampling to ensure that our sample includes diversity in terms of gender, age, countries of origin, and first and second-generation youth. Recruitment will end when data saturation is reached. Each participant will take part in a semi-structured qualitative interview. The interview explores family and social contacts, immigration/acculturation experiences, gender and cultural roles, and views on religion. Data is being transcribed and analyzed in N-Vivo 12 software using constructivist grounded principles entailing simultaneous collection and analysis, inductive construction of abstract categories explaining social processes, sampling and categorical refinement through iterative analysis, and integration of categories into a theoretical framework. RESULTS: Preliminary data analysis is in progress based on participants (n=15) recruited thus far. Emerging themes in relation to the causes of suicidality include isolation and an inability to cope with multiple stressors, such as family conflict and physical illness. Religion has a varied effect on suicidality, ranging from minimal to strong influence and from being protective to triggering suicidality. Regarding barriers to care, emerging themes included fear of invalidation, Islamophobia, and the lack of cultural safety within the healthcare system. Notably, youth appear to have a different explanatory model for mental illness compared to their family/community. CONCLUSION: This is the first qualitative study examining the experiences of Canadian Muslim youth who have experienced suicidal behavior. Our findings will help elucidate the unique stressors and protective factors that influence suicide and suicidal behavior for Canadian Muslim youth. Understanding patterns of distress and barriers to care through qualitative analysis will provide critical context to ultimately develop appropriate and effective screening, service provision, and suicide prevention strategies.

ObjectiveTo assess physician-based mental health care utilization during the COVID-19 pandemic among children and adolescents new to care and those already engaged with mental health services, and to evaluate differences by sociodemographic factors.Study designWe performed a population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada among all children and adolescents 3–17 years. We examined outpatient visit rates per 1,000 population for mental health concerns for those new to care (no physician-based mental healthcare for ≥1 year) and those with continuing care needs (any physician-based mental healthcare

Objectives There were large disruptions to health care services after the onset of the COVID pandemic. We compared outpatient primary care and mental health care physician visits before and during the COVID-19 pandemic in Ontario, Canada. Approach Population-based study of pediatric primary care and mental health visit rates after vs. before Covid restrictions. We used Poisson GEE regression to model 3-year pre-Covid trends and forecast expected trends after restrictions. The model included age, sex, a secular trend, and pre-Covid month indicators. Expected visit rates and 95% CIs post-restrictions were estimated by applying the linear combination of pre-Covid regression coefficients to the post-pandemic data and exponentiating. Relative changes in post Covid visit rates were expressed as an adjusted rate ratio of observed to expected rates by exponentiating the difference of observed and expected post-pandemic log rates and CIs. Results In a population of 2.5 million children, primary care visit rates declined by 20% of expected (adjusted rate ratio [aRR], 0.80; 95% CI, 0.77–0.82). The largest monthly decrease occurred in April 2020. Virtual visits accounted for 53% of overall visits. Although visit rates increased slowly after April 2020, they did not return to pre-restriction levels by November 2020. Mental health visit rates declined rapidly to below expected in April 2020 (aRR, 0.81; 95% CI, 0.79-0.82) followed by an increase to 7% above expected (aRR, 1.07; 95% CI, 1.04-1.09) by July 2020 and sustained at 10-15% above expected to February 2021. Adolescent females had the greatest overall increase in mental health visit rates relative to expected (aRR, 1.26; 95% CI, 1.25-1.28). Conclusion The pandemic contributed to rapid decreases in primary and mental health care, with some recovery and a shift to virtual care. There was a disproportionate increase in mental health care services among adolescent females. System-level planning to address increasing needs and monitor quality with such large shifts is warranted.

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BackgroundOpioid addiction is a major public health threat to healthy life expectancy; however, little is known of long-term mortality for mothers with opioid use in pregnancy. Pregnancy and delivery care are opportunities to improve access to addiction and supportive services. Treating neonatal abstinence syndrome (NAS) as a marker of opioid use during pregnancy, this study reports long-term maternal mortality among mothers with a birth affected by NAS in relation to that of mothers without a NAS-affected birth in 2 high-prevalence jurisdictions, England and Ontario, Canada.Methods and findingsWe conducted a population-based study using linked administrative health data to develop parallel cohorts of mother-infant dyads in England and Ontario between 2002 and 2012. The study population comprised 13,577 and 4,966 mothers of infants with NAS and 4,205,675 and 929,985 control mothers in England and Ontario, respectively. Death records captured all-cause maternal mortality after delivery through March 31, 2016, and cause-specific maternal mortality to December 31, 2014. The primary exposure was a live birth of an infant with NAS, and the main outcome was all deaths among mothers following their date of delivery. We modelled the association between NAS and all-cause maternal mortality using Cox regression, and the cumulative incidence of cause-specific mortality within a competing risks framework. All-cause mortality rates, 10-year cumulative incidence risk of death, and crude and age-adjusted hazard ratios were calculated. Estimated crude 10-year mortality based on Kaplan-Meier curves in mothers of infants with NAS was 5.1% (95% CI 4.7%-5.6%) in England and 4.6% (95% CI 3.8%-5.5%) in Ontario versus 0.4% (95% CI 0.41%-0.42%) in England and 0.4% (95% CI 0.38%-0.41%) in Ontario for controls (p < 0.001 for all comparisons). Survival curves showed no clear inflection point or period of heightened risk. The crude hazard ratio for all-cause mortality was 12.1 (95% 11.1-13.2; p < 0.001) in England and 11.4 (9.7-13.4; p < 0.001) in Ontario; age adjustment did not reduce the hazard ratios. The cumulative incidence of death was higher among NAS mothers than controls for almost all causes of death. The majority of deaths were by avoidable causes, defined as those that are preventable, amenable to care, or both. Limitations included lack of direct measures of maternal opioid use, other substance misuse, and treatments or supports received.ConclusionsIn this study, we found that approximately 1 in 20 mothers of infants with NAS died within 10 years of delivery in both England and Canada-a mortality risk 11-12 times higher than for control mothers. Risk of death was not limited to the early postpartum period targeted by most public health programs. Policy responses to the current opioid epidemic require effective strategies for long-term support to improve the health and welfare of opioid-using mothers and their children.

Introduction Opioid-use during pregnancy is indicative of future adversity for mothers and children. We aimed to investigate neonatal abstinence syndrome (NAS) as a marker of drug-use in pregnancy and to compare maternal all-cause mortality relative to those with infants born without NAS in two high prevalence jurisdictions; England and Ontario. Objectives and Approach We developed two parallel cohorts using linked mother-baby records for all births in hospitals in England and Ontario between 2002 and 2013. Mothers with opioid-use were identified based on NAS recorded in the baby’s record. Maternal mortality within 10 years of delivery was compared for mothers with and without a NAS-pregnancy. The association between opioid-use in pregnancy and all-cause mortality was modelled using Cox regression. In addition, we estimated the unadjusted cumulative incidence of cause-specific mortality within a competing risks framework. Harmonised clinical codes were used to define all exposures, outcomes and comorbidities. Results The study population comprised 13,581 and 4,966 NAS mothers in England and Ontario, respectively. Controls totalled 4,205,941 for England and 929,985 for Ontario. The crude hazard ratios for all-cause mortality were 12.1 (95% CI; 11.1-13.2) for England and 11.4 (9.7, 13.4) for Ontario, which were attenuated to 9.8 (9.0-10.6) and 9.0 (7.6, 10.7) respectively, after adjustment for maternal age at delivery and Charlson comorbidity index. The cumulative incidence of death was much higher among NAS mothers than controls for all causes except cancer in the English cohort, where estimates were similar. The majority of deaths within the NAS group were attributable to avoidable causes, particularly reflecting unintentional injuries (cumulative incidence of 19.6 (16.6-23.1) for England and 13.9 (9.7-19.3) for Ontario). Conclusion/Implications Our approach demonstrates the utility of mother-baby record linkage to examine long-term health outcomes of vulnerable families. We identified similarly high mortality rates among the mothers of NAS babies in both England and Ontario, indicating a need for public health programs to target support to mothers as well and infants.