The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie2023, Vol. 68(8) 613‐622© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/07067437231159768TheCJP.ca | LaRCP.ca
Abstract
Objectives: (1) To calculate the proportions of people who sought mental health and addiction (MHA) specialty services in Nova Scotia, overall and by sex and age. (2) To describe the health and psychosocial profiles of the MHA Intake clients. (3) To identify factors associated with acceptance for MHA services.
Methods: The data of the Nova Scotia MHA Intake clients aged 19 to 64 years old in 2020 (N = 10,178) and in 2021 (N = 12,322) were used. The proportions of unique clients in the general population were calculated based on 2021 census data. The percentages of primary presenting concerns, the presence and frequency of psychiatric symptoms in the past month, suicide risk levels, current or past provisional psychiatric diagnosis, medical problems, and psychosocial stressors were calculated. Logistic regression was conducted to identify factors associated with the acceptance of MHA services after the assessment.
Results: It was found that 1.48% and 2.33% of Nova Scotians aged 19 to 64 contacted the MHA Intake in 2020 and 2021. Over 66% were self-referrals, followed by physician referrals (28.34%). Mood (28.3%), anxiety (25.17%), and substance use (19.81%) were the top three presenting concerns for the contact. Many clients had a current or past provisional psychiatric diagnosis (58.7% in 2020, 61.8% in 2021). Among the clients, 74.67% and 68.29% reported at least 1 psychosocial stressor in 2020 and 2021, respectively. The clients with a current or past psychiatric diagnosis, suicide risk, and 2 or more psychosocial stressors, those who lived outside of Central Zone, and who had employee assistance program benefits/private insurance, were more likely to be qualified and accepted for MHA services than others.
Conclusions: The Intake clients have complex health and psychosocial profiles. Future studies are needed to monitor the trajectories of the clients to reduce inequities in receiving MHA services and improve client outcomes.
Résumé
Objectifs: (1) Calculer les proportions de gens qui ont recherché des services spécialisés en santé mentale et en dépendance (SMD) en Nouvelle-Écosse en général et selon le sexe et l’âge. (2) Décrire les profils de santé et psychosociaux des clients de l’admission en SMD. (3) Identifier les facteurs associés à l’acceptation des services SMD.
Méthodes: Les données des clients de l’admission en SMD, âgés de 19 à 64 ans en Nouvelle-Écosse en 2020 (N = 10,178) et en 2021 (N = 12,322) ont été utilisées. Les proportions de clients uniques de la population générale ont été calculées d’après les données du recensement de 2021. Les pourcentages des principales préoccupations présentées, la présence et la fréquence des symptômes psychiatriques le mois précédent, les niveaux de risque de suicide, le diagnostic psychiatrique provisoire actuel ou passé, les problèmes médicaux, et les stresseurs psychosociaux ont été calculés. La régression logistique a été menée pour identifier les facteurs associés à l’acceptation des services SMD après l’évaluation.
Résultats: Il a été constaté que 1,48% et 2,33% des Néo-Écossais de 19 à 64 ans ont contacté l’admission en SMD en 2020 et 2021. Plus de 66% étaient des autoréférences, suivis de références d’un médecin (28,34%). L’humeur (28,3%), l’anxiété (25,17%) et l’utilisation de substances (19,81%) étaient les trois principales préoccupations qui se présentaient pour le contact. Nombre de clients avaient un diagnostic psychiatrique provisoire actuel ou passé (58,7% en 2020, 61,8% en 2021). Parmi les clients, 74,67% et 68,29% rapportaient au moins un stresseur psychosocial en 2020 et en 2021, respectivement. Les clients ayant un diagnostic psychiatrique passé ou actuel, un risque de suicide et deux stresseurs psychosociaux ou plus, ceux qui habitaient hors de la Zone centrale, et qui avaient des prestations du programme d’aide aux employés/assurance privée, étaient plus susceptibles que d’autres d’être qualifiés et acceptés aux services SMD.
Conclusions: Les clients de l’admission ont des profils de santé et psychosociaux complexes. Il faut de futures études pour surveiller les trajectoires des clients et réduire les inégalités de la réception des services SMD et améliorer les résultats des clients.
Keywordsmental health and addiction, specialty services, central intake/triage, mental health needs, mental health services, service planning.
The 2012 Canadian Community Health Survey—Mental Health showed that the lifetime and annual prevalence of mental or substance use-related disorders in Nova Scotia was 41.7% and 13.2%, respectively, which were the highest among Canadian provinces.1 There are also high rates of co-occurring disorders and a complex interplay amongst substance use, addiction, mental health, and physical health problems.2–7 Like other provinces and territories, mental health and addiction (MHA) services in Nova Scotia are delivered through community and hospitals, and MHA supports are provided in a heterogeneous variety of settings and address a mix of severities. A key and complex challenge under these conditions is how to define and quantify the MHA needs at the population level and plan MHA services based on the needs.
To plan for and address population-based needs for MHA services, Kurdyak and Patten8 proposed 3 areas of the required information: population-based prevalence estimates, the needs of the population seeking MHA services, and the effectiveness of the services. The 2 national mental health surveys in 20029 and 201210 generated populationbased prevalence estimates for selected mental disorders. There are also a number of Canadian studies on the MHA services use among those who received MHA services using health administrative data such as physician billing, hospitalization, and emergency department (ED) visits.11–19 In Canada, most people with an MHA problem are first seen by primary care physicians, and a physician’s referral is often needed to access specialized MHA services.20 However, many people with MHA needs do not receive the services in a timely manner due to various barriers to care.21 Thus, existing health administrative databases only capture the people who received MHA services. Regional centralized access points where information at the point of referral is routinely captured may offer better information to align services with needs at a regional population level.8
To address the challenges of MHA services access and integration, Nova Scotia adopted a tiered framework (5 tiers) when planning and delivering MHA services (Supplemental file #1: Figure 1) and established a provincial centralized MHA Intake process.22 The top 3 tiers cover MHA specialty services provided by the MHA clinicians in Nova Scotia Health (NSH) and IWK (<19 years of age) hospitals and clinics; services in the bottom 2 tiers include MHA supports provided through primary care, other community sources, and health education and promotion. The centralized intake process was designed to facilitate access to specialized MHA services that Nova Scotians need, and to provide the same access to specialized MHA services through a single, toll-free telephone number no matter where you are in the province and whether you have a physician referral.22 A single point of access supports a consistent referral and assessment process and ensures that those in need get referred to the right practitioner for their level of need.22 However, the MHA Intake does not make a diagnosis during the assessment. After the assessment, a client may be qualified and accepted for MHA services, directed to other community resources, or provided with a brief intervention. In essence, the MHA Intake is the entry point of MHA specialty services at the top 3 tiers in Nova Scotia. The MHA Intake has been in full operation since 2019. Because the MHA Intake is open to anyone with perceived mental health needs in the province, the data from these assessments provide a unique opportunity for understanding the population who seek MHA services in terms of their demographic characteristics and mental and psychosocial needs. Such information can be useful for informing MHA services planning in relation to the needs of the population. The objectives of this study were to: (1) calculate the proportions of people who contacted the central intake in Nova Scotia overall and by sex and age; (2) describe the health and psychosocial profiles of the MHA Intake clients in 2020 and 2021; (3) identify factors associated with being accepted for MHA services after the assessments.
For the objectives of this study, data collected at the MHA Intake from January 2020 to December 2021 were included. We did not include data collected in 2019 as the MHA Intake was only in operation for several months in 2019. The MHA Intake covers the population across 4 health zones (Northern, Eastern, Western, and Central) and all ages. This study focused on clients aged 19 and 64 years old, because (1) patients aged 18 or younger in the Central Zone, except West Hants, are served by IWK, and (2) seniors aged 65+ years in the Central Zone are referred directly to the geriatric specialty services. These 2 subpopulations do not go through the MHA Intake. This study was approved by the Research Ethics Board of the NSH Authority.
The intake screening assessment is conducted by MHA clinicians (e.g., clinical therapists, social workers, and registered nurses) using a semistructured interview through telephone (in limited circumstances, face-to-face intake assessment), informed by the MHA Intake Triage Assessment with embedded Triage Acuity Guide. Responses from the interview are captured on the electronic Intake Assessment form which upon completion is integrated into the permanent health record. The interviewers underwent a 3-week orientation and training process before conducting the screening assessment. The interview includes symptom screening, history of presenting concerns, needs assessment, suicide risk assessment, exploring concerns around self-care activities, developmental concerns, medications, supports and resources, medical and psychiatric history, and prior treatment sought.
Demographic and socioeconomic information: Age, marital status, income sources, ethnicity, living conditions, referral sources, access to employee assistance program (EAP) or private insurance, and health zones. The MHA Intake did not collect data about biological sex. We extracted the data about sex from patient registration which is a separate database and is not linked with the MHA Intake.
Presence and frequency of psychiatric symptoms: The interviewers asked screening questions to explore symptomology experienced by an individual over the past month, including frequency and impact on function. The symptom domains included mood, anxiety, psychosis, trauma, cognition, behaviors, and general (e.g., eating, dieting, and sleep) (see Supplemental file #2). For each domain, the client may answer “yes” or “no” for the presence of the symptom. If “yes” was selected, further questions about the frequency over the past month were asked. The interviewer chose the overall impact on functionality as mild, moderate, or severe, based on the frequency of the symptoms and clinical judgment. For this analysis, we categorized each symptom domain as no symptom, with symptoms with a categorization of minimal, mild, moderate, and severe impact on functionality.
Presence of current or past provisional diagnosis of mental disorders: The presence of 13 different disorders was investigated based on client self-report, including depression, anxiety, bipolar disorders, attention-deficit/hyperactivity disorder, adjustment disorder, autism, eating disorder, neurocognitive disorder, obsessive-compulsive disorder, personality disorder, psychotic disorder, posttraumatic stress disorder, and substance use disorder. In this analysis, we classified clients into the categories of 0, 1, 2, and 3+ disorders groups.
Presence of current or history of medical problems: On interview, the followings were explored based on client selfreport: brain injury, concussion, seizure, stroke, chronic pain, fibromyalgia, obesity, dyslipidemia, hypertension, heart disease, hyperthyroid, kidney disease, liver disease, cancer, respiratory disease, diabetes, menstrual-related disorder, hematologic disease, and “other.” In this analysis, we classified clients into the categories of 0, 1, 2, and 3+ disease groups.
Levels of suicide risk: At the assessment, clients were asked “Have you had thoughts about suicide or wanting to be dead in the past 2 weeks?,”“Have you tried to kill yourself or attempt suicide in the past?” and “Do you have thoughts of suicide now?” If 1 answered “yes” to 1 of the questions, a detailed suicide risk assessment23 was conducted. The interviewer classified the client into low, moderate, or high suicide risk levels.
Primary presenting mental health concern: The client was asked to identify the primary mental health concern for which they contacted the Intake to seek MHA services.
Psychosocial stressors: The client was asked to identify if he/she experienced any of the following 15 stressors that may affect their current function (see Supplemental file #2). The interviewer probed for the presence of stressors by offering specific examples. For example, for financial stressors, the client was asked if he/she is experiencing poor or unstable finances, potential loss of income source, or no income at all.
Final disposition: There are 3 broad disposition outcomes after the assessment: (1) accepted for MHA services (i.e., qualified for and will be referred to local MHA specialty services), (2) redirected to other community resources (e.g., Canadian Mental Health Association, primary care, crisis line, Departments of Justice or Community Services, online resources, EAP, and others), and (3) closed (only a brief consultation session is needed, services declined, and assessment not completed). The final disposition was based on criteria for services suitability and Triage Acuity Guide that are internally established and followed by all interviewers.
We calculated the proportions of individuals who contacted the MHA Intake in 2020 and 2021, overall, and by sex and age groups. The numerator is the unique clients each year; the denominator is the population counts in Nova Scotia in the 2021 census overall and by sex and age groups.24
We calculated the proportions of the client assessments by demographic characteristics, primary mental health concerns, presence of current/past mental health diagnosis and of medical problems, and the number of psychosocial stressors that affected their function. Logistic regression modeling was conducted to identify factors associated with being accepted for MHA services after the assessment. Multinomial logistic regression modeling was used to investigate the differences between the clients who were redirected to community resources and those who were closed in their health and psychosocial profiles. It should be noted that some clients may have contacted the MHA Intake multiple times each year for different mental health concerns. Therefore, the analyses of the demographics, health, and psychosocial characteristics as well as logistic regression modeling were based on assessment records, rather than unique clients.
In the 2021 census, 579,180 people were between the ages of 19 and 64 years old in Nova Scotia. In 2020 and 2021, 8,572 (1.48%) and 13,487 (2.33%) unique individuals contacted the MHA Intake, respectively. As seen from Table 1, the percentages of contacting the Intake were higher in females than in males, irrespective of age and years. The percentages of contacting the Intake decreased with the increase of age, irrespective of sex and years.
The demographic characteristics of the clients are listed in Table 2. A large proportion of the clients came from the Central Zone which is the most populous health region in Nova Scotia. The clients came from different sources. Over 66% of the clients were self-referrals, followed by physician or nurse practitioner referrals (28.34%). About 60% of the clients are White and about 4% are indigenous people. Most of the clients (94.59%) lived in private dwellings or rentals. Less than one-third had private insurance or EAP benefits.
Table 3 contains the proportions of the presence and frequency of various mental and physical health characteristics. The data showed that about 80% of the clients reported mood and/or anxiety symptoms in the past month, followed by about 50% with trauma-related symptoms or cognitive symptoms, about 40% with behavioral problems, and over 12% with psychotic symptoms. Many clients had a current or past provisional psychiatric diagnosis (58.7% in 2020, 61.8% in 2021) and a history of medical problems (59.43% in 2020, 62.52% in 2021). Over 37% of clients reported suicidal behaviors. Mood, anxiety, and substance and addictionrelated issues were the top 3 primary presenting concerns for making the contact, followed by trauma and stress, personality, and psychotic problems (Supplemental file#1: Figure 2). Among the clients, 74.67% and 68.29% reported at least 1 psychosocial stressor in 2020 and 2021, respectively (Table 4). The top 3 psychosocial stressors were related to family and significant relationships, poor or unstable finance, and experience of traumatic events. Childhood adversities were reported in about 5% of the population.
After the assessment, 80.68% and 81.26% of the patients were accepted for MHA services in 2020 and 2021, respectively. The rest were either directed to other community resources (15.67% in 2020, 16.15% in 2021) or closed (1.74% in 2020, 2.59% in 2021). The proportion of acceptance for MHA services in self-referred clients was higher than that in those referred by physicians in 2020 (84.24% vs. 77.61%, p < 0.0001) but not in 2021 (80.95% vs. 82.22%, p = 0.32). Logistic regression modeling showed that clients who were aged 30 to 49 years, single, not living in Central Zone, on Employment Insurance (EI)/ pension/social assistance/disability benefits, self-referral, had EAP or private insurance, reported suicide behaviors, had a past or current provisional psychiatric diagnosis, and reported 2+ psychosocial stressors, were more likely to be accepted for MHA services than others (Table 5). The multinomial logistic regression model showed that being single (relative risk ratio [RRR] = 0.74, 95% confidence interval [CI], 0.59 to 0.92), having received income from EI/ pension/social assistance/disability benefits (RRR = 0.64, 95% CI, 0.51 to 0.80), being referred by others (RRR = 0.41, 95% CI, 0.28 to 0.61), living in Eastern (RRR = 0.13, 95% CI, 0.10 to 0.16) and Northern Zone (RRR = 0.34, 95% CI, 0.24 to 0.49) were less likely to be redirected to community resources than being closed. However, those living in Western Zone (RRR = 1.48, 95% CI, 1.05 to 2.07) and having 1 or more medical conditions (RRR = 2.85, 95% CI, 2.27 to 3.59) were more likely to be redirected to the community resources than being closed. The 2 groups did not differ in other factors.
In Nova Scotia, about 1.5% to 2.3% of the general population contacted the MHA Intake to seek MHA specialty services. A large proportion of them were self-referrals. The top 3 presenting concerns were mood, anxiety, and substance use-related problems. This population manifested complex mental health needs as reflected by the presence of various mental health symptoms, ongoing and past mental and medical problems, and prevalent psychosocial stressors. Relationship, financial and trauma-related issues appeared to be the predominant psychosocial stressors among the clients. Over 80% of the clients were accepted for MHA services after the assessment. Individuals with more diagnoses, psychosocial stressors, and suicide behaviors were more likely to be accepted than others. There also appeared to be differences in acceptance for MHA services by age, health zones, and whether 1 had EAP or private insurance.
The results of this study should be interpreted in the context of the MHA Intake operation in Nova Scotia. Despite the implementation of the Intake service, some people may visit ED for MHA services or use ED as the first point of contact for MHA services.13,17,19 In Nova Scotia, several specialty MHA programs such as Early Psychosis Intervention, Mood Disorder Program, and Opioid Use Program take referrals directly from ED, primary care physicians, schools, and self/family referrals. Therefore, the observed proportions of contacting the MHA Intake are an underestimation of people who need MHA specialty services in Nova Scotia. The denominators of the observed proportions (1.5% to 2.3%) are the overall population counts. The proportions of contacting the Intake among people with MHA needs (e.g., meeting the diagnostic criteria for a mental disorder or having perceived MHA need) are unknown. Linking the Intake and other health administrative databases and population health surveys may help address these issues. The data of this analysis were collected in 2020 and 2021 through the period of the pandemic. People’s needs for MHA services may change with further removal of public health restriction measures and gradually moving back to the pre-COVID status in work, school, and daily life. Therefore, the Intake clients’ needs and health and psychosocial profiles in the “post-pandemic” era may change and should be examined and compared in future analyses. Some clients who were at high risk of suicide were immediately redirected to Crisis Line for intervention before the assessment was completed. This may explain the relatively low proportion of moderate to high risk of suicide in this study.
About 1.5% to 2.3% of Nova Scotians demonstrated an interest in being assessed for MHA specialty services through the newly implemented MHA Intake line. The proportion of people who need MHA specialty services may vary by region. Presently, Nova Scotia is the only province in Canada that has implemented a provincial Intake service. Therefore, a direct comparison with other provinces and with previous studies is not possible. The annual prevalence of MHA problems in Nova Scotia was 13.2%.1 It is possible that the majority of individuals had mild to moderate MHA problems and can be effectively managed through the traditional primary care system and community resources (e.g., through Tier 1 and 2 in the tiered model), with primary care physicians providing approximately 80% of MHA care.25 Therefore, it is appropriate for 1.5% to 2.3% of the general population (albeit an underestimation) to seek screening for access to specialized MHA services. Integration of various MHA specialty programs and health administrative databases will provide more accurate estimates of needs for MHA specialty services.
The MHA Intake clients are highly heterogeneous in demographic characteristics, symptoms, severity, and presenting concerns. Their health and psychosocial profiles are complex in terms of comorbidity between mental and physical conditions and psychosocial stressors. Many reported finance, relationship, and trauma-related issues, which highlight the substantial need for the cognitive behavioral therapy and relationship interventions provided by health professionals and/or by e-health programs. The goal of the Intake is to match the clients to community MHA services according to their needs. Therefore, it is expected that individuals with more psychiatric diagnoses, psychosocial stressors, and suicide behaviors were more likely to be qualified and accepted than others.
It was found that clients aged 30 to 49 years old, who were single, self-referral, living outside of the Central Zone, or had EAP/private insurance, were more likely to be accepted for MHA services. It is not entirely clear why acceptance for MHA services differed by these factors. Having EAP benefits or private insurance is not a criterion for qualification and acceptance for MHA services at the Intake. Perhaps, clients who have EAP benefits or private insurance may be more likely to reach out for help than those who do not have. Although the Central Zone may have the most MHA resources among the 4 health regions, it is also the most populous health zone in Nova Scotia. Because of the population size, the demand for MHA services may exceed the supply, which may hinder the qualification and acceptance of MHA services in this region. Additional analysis found that Central Zone did not differ from other regions in client characteristics, except that more Black and Asian clients were from Central Zone. It is also possible that the observed differences by age, marital status, insurance status, and geographic location may be normal variations among people with conditions that were less appropriate for specialized care. Future studies are needed to monitor whether the differences persist. If the differences represent the disparities in acceptance of MHA services and redirection to other community resources, they should be considered in MHA service planning and policy development.
The strengths of this study included the use of all individuals who sought MHA services in Nova Scotia, instead of a sample. There are several limitations. First, this study relied on cross-sectional data. We observed disparities in the acceptance of MHA services by demographic and health characteristics. However, we cannot draw conclusions about causal relationships. Second, the MHA Intake did not collect information about biological sex. Data about sex are in a different database which cannot be linked at this stage. Therefore, sexspecific analysis cannot be conducted. There is a large proportion of missing data associated with ethnicity (about 30%) and access to private insurance (about 20%). Results related to these 2 variables need to be interpreted with caution. Third, data about the health and psychosocial profiles relied on self-report. Recall and reporting biases are possible. Fourth, this study relied on the data collected in Nova Scotia. The results may not be applicable to other provinces and regions. Finally, this analysis did not present the profiles of substance use and addiction behaviours. The MHA Intake collected extensive information about substance use, alcohol, tobacco, and other drugs. For the consideration of clarity and space limitation, we decided to examine the profile of substance use and addiction behaviours in a separate analysis.
In summary, about 1.5% to 2.3% of the Nova Scotia general population demonstrated the need for MHA services. The health and psychosocial profiles highlight the complex mental health needs of this population. This study used the data collected in 2020 and 2021. Future studies are needed to compare the changes in the health and psychosocial profiles of the clients after the pandemic is over. Furthermore, future studies need to longitudinally monitor the patterns of MHA services use among clients who were and who were not accepted for MHA services, and if inequities in services use exist, to identify perceived and actual barriers to care. The results of such studies will be useful for informing MHA services planning and delivery.
Data access: The data that support the findings of this study are the property of NSH Authority, and therefore, may be accessible, pending the approval of the data custodian.
We would like to acknowledge Subathra Vijayakumar and Wendy Clark at the MHA Program, NSH, for their assistance in data extraction.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The analysis is supported by a Canada Research Chair award to JLW, Canadian Institutes of Health Research, (grant number Canada Research Chair in Health Data Science and Innovation).
JianLi Wang https://orcid.org/0000-0002-1329-914X
Supplemental material for this article is available online.
1 Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Halifax, Canada
2 Department of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Halifax, Canada
3 Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
4 Early Psychosis Intervention Nova Scotia, Nova Scotia Health, Halifax, Nova Scotia, Halifax, Canada
5 Mental Health and Addiction Program, Nova Scotia Health, Halifax, Nova Scotia, Halifax, Canada
Corresponding author:JianLi Wang, 5790 University Ave. Halifax, NS, Canada B3H 1V7.Email: jianli.wang@dal.ca
