Screening and Treatment of Posttraumatic Stress Disorder in Wildfire Evacuees: A Cost-Utility Analysis.

Background. Global climate change is resulting in dramatic increases in wildfires. Individuals exposed to wildfires experience a high burden of posttraumatic stress disorder (PTSD), and the cost-effectiveness of the treatment options to address PTSD from wildfires has not been studied. The objective of this study was to conduct a cost-utility analysis comparing screening followed by treatment with paroxetine or trauma-focused cognitive behavioral therapy (TF-CBT) versus no screening in Canadian adult wildfire evacuees. Methods. Using a Markov model, quality-adjusted life-years (QALYs) and costs were evaluated over a 5-y time horizon using health care and societal perspectives. All costs and utilities in the model were discounted at 1.5%. Probabilistic and deterministic sensitivity analyses examined the uncertainty in the incremental net monetary benefit (INMB) under a willingness-to-pay threshold of $50,000. Results. From a societal perspective, no screening (NMB = $177,641) was dominated by screening followed by treatment with paroxetine (NMB = $180,733) and TF-CBT (NMB = $181,787), with TF-CBT having the highest likelihood of being cost-effective at a willingness-to-pay threshold of $50,000 per QALY (probability = 0.649). The initial prevalence of PTSD, probability of acceptance of treatment, and costs of productivity had the largest impact on the INMB of both paroxetine or TF-CBT versus no screening. Neither intervention was cost-effective at a willingness-to-pay threshold of $50,000 per QALY from a health care perspective. Interpretation. Screening followed by treatment with paroxetine or TF-CBT compared with no screening was found to be cost-saving while providing additional QALYs in wildfire evacuees. Governments should consider funding screening programs for PTSD followed by treatment with TF-CBT for wildfire evacuees. Highlights: Two prior studies examined the cost-effectiveness of screening followed by treatment for PTSD among individuals exposed to other disaster-type events (i.e., terrorist attack and Hurricane Sandy) and found screening followed by treatment (i.e., cognitive behavioral therapy [CBT]) to be highly cost-effective.Among wildfire evacuees, screening followed by treatment with paroxetine or trauma-focused (TF)-CBT provides additional quality-adjusted life-years (QALYs) and is cost-saving from a societal perspective. TF-CBT was the treatment option found most likely to be cost-effective.Neither treatment option was cost-effective at a willingness-to-pay threshold of $50,000 per QALY from a health care perspective.Screening programs for PTSD should be considered for wildfire evacuees, and individuals diagnosed with PTSD could be prescribed either TF-CBT or paroxetine depending on their preference and resources availability.

COVID-19 Pandemic, Physical Distancing Policies, and the Non-Profit Sector Volunteer Force.

Although COVID-19-related physical distancing has had large economic consequences, the impact on volunteerism is unclear. Using volunteer position postings data from Canada's largest volunteer center (Volunteer Toronto) from February 3, 2020, to January 4, 2021, we evaluated the impact of different levels of physical distancing on average views, total views, and total number of posts. There was about a 50% decrease in the total number of posts that was sustained throughout the pandemic. Although a more restrictive physical distancing policy was generally associated with fewer views, there was an initial increase in views during the first lockdown where total views were elevated for the first 4 months of the pandemic. This was driven by interest in COVID-19-related and remote work postings. This highlights the community of volunteers may be quite flexible in terms of adapting to new ways of volunteering, but substantial challenges remain for the continued operations of many non-profit organizations.

Child health and its effect on adult social capital accumulation.

Although studies have demonstrated important effects of poor health in childhood on stocks of human and health capital, little research has tested economic theories to investigate the effect of child health on social capital in adulthood. Studies on the influence of child health on adult social capital are mixed and have not used sibling fixed effects models to account for unmeasured family and genetic characteristics, that are likely to be important. Using the Add-Health sample, health in childhood was assessed as self-rated health, the occurrence of a physical health condition or mental health condition, while social capital in adulthood was measured as volunteering, religious service attendance, team sports participation, number of friends, social isolation, and social support. We used sibling fixed effects models, which attenuated several associations to non-significance. In sibling fixed effects models there was significant positive effects of greater self-rated health on participation in team sports and social support, and negative effect of mental health in childhood on social isolation in adulthood. These results suggest that children with poor health require additional supports to build and maintain their stock of social capital and highlight further potential benefits to efforts that address poor child health.

Genetic endowments for social capital: An investigation accounting for genetic nurturing effects.

Despite social capital having been shown to be important for health and well-being, relatively little research has examined genetic determinants. Genetic endowments for education have been shown to influence human, financial, and health capital, but few studies have examined social capital, and those conducted have yet to account for genetic nurturing. We used the Add-Health data to study the effect of genetic endowments on individual social capital using the education polygenic score (PGS). We used sibling fixed effects models and controlled for the family environment to account for genetic nurturing. After accounting for the family environment, we found moderately large significant associations between the education PGS and volunteering, but associations with religious service attendance and number of friends were completely attenuated in sibling fixed effects models. These findings highlight that genetic endowments play an important role in influencing volunteering and the importance of accounting for genetic nurturing.

The Association Between Prior Mental Health Service Utilization and Risk of Recidivism among Incarcerated Ontario Residents.

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 < 0.001), with secondary analyses finding larger associations for addiction service use (HR range: 1.34-1.54, all P < 0.001) than for mental health service use (HR range: 1.09-1.18, all P < 0.001). We found high levels of post-release MHA hospitalization and low levels of outpatient MHA care relative to need even among individuals with prior MHA hospitalization. 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.

SARS-CoV-2 vaccination prevalence by mental health diagnosis: a population-based cross-sectional study in Ontario, Canada.

BACKGROUND: Since the onset of the COVID-19 pandemic, there has been concern about the impact of SARS-CoV-2 infection among individuals with mental illnesses. We analyzed the SARS-CoV-2 vaccination status of Ontarians with and without a history of mental illness. METHODS: We conducted a population-based cross-sectional study of all community-dwelling Ontario residents aged 19 years and older as of Sept. 17, 2021. We used health administrative data to categorize Ontario residents with a mental disorder (anxiety, mood, substance use, psychotic or other disorder) within the previous 5 years. Vaccine receipt as of Sept. 17, 2021, was compared between individuals with and without a history of mental illness. RESULTS: Our sample included 11 900 868 adult Ontario residents. The proportion of individuals not fully vaccinated (2 doses) was higher among those with substance use disorders (37.7%) or psychotic disorders (32.6%) than among those with no mental disorders (22.9%), whereas there were similar proportions among those with anxiety disorders (23.5%), mood disorders (21.5%) and other disorders (22.1%). After adjustment for age, sex, neighbourhood income and homelessness, individuals with psychotic disorders (adjusted prevalence ratio 1.19, 95% confidence interval [CI] 1.18-1.20) and substance use disorders (adjusted prevalence ratio 1.35, 95% CI 1.34-1.35) were more likely to be partially vaccinated or unvaccinated relative to individuals with no mental disorders. INTERPRETATION: Our study found that psychotic disorders and substance use disorders were associated with an increased prevalence of being less than fully vaccinated. Efforts to ensure such individuals have access to vaccinations, while challenging, are critical to ensuring the ongoing risks of death and other adverse consequences of SARS-CoV-2 infection are mitigated in this high-risk population.

Association of source country gender inequality with experiencing assault and poor mental health among young female immigrants to Ontario, Canada.

BACKGROUND: Gender inequality varies across countries and is associated with poor outcomes including violence against women and depression. Little is known about the relationship of source county gender inequality and poor health outcomes in female immigrants. METHODS: We used administrative databases to conduct a cohort study of 299,228 female immigrants ages 6-29 years becoming permanent residence in Ontario, Canada between 2003 and 2017 and followed up to March 31, 2020 for severe presentations of suffering assault, and selected mental health disorders (mood or anxiety, self-harm) as measured by hospital visits or death. Poisson regression examined the influence of source-country Gender Inequality Index (GII) quartile (Q) accounting for individual and country level characteristics. RESULTS: Immigrants from countries with the highest gender inequality (GII Q4) accounted for 40% of the sample, of whom 83% were from South Asia (SA) or Sub-Saharan Africa (SSA). The overall rate of assault was 10.9/10,000 person years (PY) while the rate of the poor mental health outcome was 77.5/10,000 PY. Both GII Q2 (Incident Rate Ratio (IRR): 1.48, 95% Confidence Interval (CI): 1.08, 2.01) and GII Q4 (IRR: 1.58, 95%CI: 1.08, 2.31) were significantly associated with experiencing assault but not with poor mental health. For females from countries with the highest gender inequality, there were significant regional differences in rates of assault, with SSA migrants experiencing high rates compared with those from SA. Relative to economic immigrants, refugees were at increased risk of sustaining assaults (IRR: 2.96, 95%CI: 2.32, 3.76) and poor mental health (IRR: 1.73, 95%CI: 1.50, 2.01). Higher educational attainment (bachelor's degree or higher) at immigration was protective (assaults IRR: 0.64, 95%CI: 0.51, 0.80; poor mental health IRR: 0.69, 95% CI: 0.60, 0.80). CONCLUSION: Source country gender inequality is not consistently associated with post-migration violence against women or severe depression, anxiety and self-harm in Ontario, Canada. Community-based research and intervention to address the documented socio-demographic disparities in outcomes of female immigrants is needed.

The effect of mental health on social capital: An instrumental variable analysis.

Although a large body of literature has examined the effect of social capital on health and theoretical models suggest a reciprocal relationship between the two variables, there are relatively few studies that have investigated the effect of mental health on social capital. This paper evaluates the impact of mental health on the stock of social capital using data from the cross-sectional 2012 (N = 21,844) and 2002 (N = 31,089) Canadian Community Health Survey - Mental Health editions. Mental health was measured retrospectively as self-rated mental health, past year mental health conditions, and past 30-day psychological distress. Given the reciprocal relationship, we used an instrumental variable approach with family history of mental health problems as the instrument and examined forms of social capital - sense of belonging and workplace social support - that are largely measures of social capital provided by non-family members in the community and workplace. The analysis suggests there are large and significant associations between measures of mental health and both outcomes, which persist in the instrumental variable analyses. These findings highlight the urgent need for policy makers to implement greater prevention and treatment of poor mental health, and provide greater support for individuals with poor mental health so they can build and maintain their social capital.

Does physician compensation for declaration of involuntary status increase the likelihood of involuntary admission? A population-level cross-sectional linked administrative database study.

BACKGROUND: There is substantial variability in involuntary psychiatric admission rates across countries and sub-regions within countries that are not fully explained by patient-level factors. We sought to examine whether in a government-funded health care system, physician payments for filling forms related to an involuntary psychiatric hospitalization were associated with the likelihood of an involuntary admission. METHODS: This is a population-based, cross-sectional study in Ontario, Canada of all adult psychiatric inpatients in Ontario (2009-2015, n = 122 851). We examined the association between the proportion of standardized forms for involuntary admissions that were financially compensated and the odds of a patient being involuntarily admitted. We controlled for socio-demographic characteristics, clinical severity, past-health care system utilization and system resource factors. RESULTS: Involuntary admission rates increased from the lowest (Q1, 70.8%) to the highest (Q5, 81.4%) emergency department (ED) quintiles of payment, with the odds of involuntary admission in Q5 being nearly significantly higher than the odds of involuntary admission in Q1 after adjustment (aOR 1.73, 95% CI 0.99-3.01). With payment proportion measured as a continuous variable, the odds of involuntary admission increased by 1.14 (95% CI 1.03-1.27) for each 10% absolute increase in the proportion of financially compensated forms at that ED. CONCLUSIONS: We found that involuntary admission was more likely to occur at EDs with increasing likelihood of financial compensation for invoking involuntary status. This highlights the need to better understand how physician compensation relates to the ethical balance between the right to safety and autonomy for some of the world's most vulnerable patients.

Discharge and post-discharge outcomes of psychiatric inpatients with a lifetime history of exposure to interpersonal trauma: A population-based study.

OBJECTIVE: To examine discharge and post-discharge outcomes for psychiatric inpatients with a history of exposure to physical, sexual, or emotional trauma. METHODS: In this population-based cohort study using health-administrative data, adult psychiatric inpatients in Ontario, Canada (2009-2016) with and without self-reported lifetime exposure to interpersonal trauma were compared on their likelihood of: discharge against medical advice; post-discharge outpatient follow-up; and post-discharge emergency department (ED) visits, rehospitalization, deliberate self-harm and suicide. Modified Poisson regressions generated relative risks (aRR) and 95% confidence intervals (CI), adjusted for age, sex, income, medical comorbidities, and psychiatric diagnosis. RESULTS: Psychiatric inpatients with a history of interpersonal trauma (n = 50,832/160,436, 31.7%) were at elevated risk for discharge against medical advice (5.6% vs. 4.6%; aRR = 1.27, 1.21-1.33), and for 1-year post-discharge psychiatric ED visits (31.0% vs. 28.3%, aRR = 1.04, 1.02-1.06), and deliberate self-harm (5.5% vs. 3.7%, aRR = 1.30, 1.23-1.36). Post-discharge 30-day follow-up with primary care was slightly more common among those with a trauma history (37.6% vs. 34.5%, aRR = 1.06, 1.04-1.08); psychiatrist follow-up was less common (35.1% vs. 37.1%, aRR = 0.87, 0.86-0.89). Elevations in risk were observed for those with primary diagnoses of psychotic, mood and anxiety disorders, but not for those with a primary diagnosis of substance-related disorders. Risk elevations were specifically observed in those without a diagnosis of post-traumatic stress disorder. CONCLUSION: Implementing supports and services during and after inpatient hospitalization that take into account a history of interpersonal trauma may help reduce certain undesirable discharge and post-discharge outcomes in this slightly higher-risk group.

Physician-based availability of psychotherapy in Ontario: a population-based retrospective cohort study.

BACKGROUND: Psychotherapy is recommended as a first-line treatment for the management of common psychiatric disorders. The objective of this study was to evaluate the availability of publicly funded psychotherapy provided by physicians in Ontario by describing primary care physicians (PCPs) and psychiatrists whose practices focus on psychotherapy and comparing them to PCPs and psychiatrists whose practices do not. METHODS: This was a population-based retrospective cohort study. We included all PCPs and psychiatrists in Ontario who submitted at least 1 billing claim to the Ontario Health Insurance Plan between Apr. 1, 2015, and Mar. 31, 2016, and categorized them as psychotherapists if at least 50% of their outpatient billings were related to the provision of psychotherapy. We measured practice characteristics such as total number of patients and new patients, and average visit frequency for 4 physician categories: PCP nonpsychotherapists, PCP psychotherapists, psychiatrist nonpsychotherapists and psychiatrist psychotherapists. We also measured access to care for people with urgent need for mental health services. RESULTS: Of 12 772 PCPs, 404 (3.2%) were PCP psychotherapists; of 2150 psychiatrists, 586 (27.3%) were psychotherapists. Primary care physician nonpsychotherapists had the highest number of patients and number of new patients, followed by psychiatrist nonpsychotherapists, PCP psychotherapists and psychiatrist psychotherapists. Primary care physician nonpsychotherapists had the lowest average annual number of visits per patient, whereas both types of psychotherapists had a much greater number of visits per patient. Primary care physician and psychiatrist nonpsychotherapists saw about 25% of patients with urgent needs for mental health services, whereas PCP and psychiatrist psychotherapists saw 1%-3% of these patients. INTERPRETATION: Physicians who provide publicly funded psychotherapy in Ontario see a small number of patients, and they see few of those with urgent need for mental health services. Our findings suggest that improving access to psychotherapy will require the development of alternative strategies.

Evaluating the Cost Effectiveness of a Suicide Prevention Campaign Implemented in Ontario, Canada.

BACKGROUND: Although suicide-prevention campaigns have been implemented in numerous countries, Canada has yet to implement a strategy nationally. This is the first study to examine the cost utility of the implementation of a multidimensional suicide-prevention program that combines several interventions over a 50-year time horizon. METHODS: We used Markov modeling to capture the dynamic changes to health status and estimate the incremental cost per quality-adjusted life-year gained over a 50-year period for Ontario residents for a suicide-prevention strategy compared to no intervention. The strategy consisted of a package of interventions geared towards preventing suicide including a public health awareness campaign, increased identification of individuals at risk, increased training of primary-care physicians, and increased treatment post-suicide attempt. Four health states were captured by the Markov model: (1) alive and no recent suicide attempt; (2) suicide attempt; (3) death by suicide; (4) death (other than suicide). Analyses were from a societal perspective where all costs, irrespective of payer, were included. We used a probabilistic analysis to test the robustness of the model results to both variation and uncertainty in model parameters. RESULTS: Over the 50-year period, the suicide-prevention campaign had an incremental cost-effectiveness ratio (ICER) of $18,853 (values are in Canadian dollars) per QALY gained. In all one-way sensitivity analyses, the ICER remained under $50,000/QALY. In the probabilistic analysis, there was a probability of 94.8% that the campaign was cost effective at a willingness-to-pay of $50,000/QALY (95% confidence interval of ICER probabilistic distribution: 2650-62,375). Among the current population, the intervention was predicted to result in the prevention of 4454 suicides after 50 years (1033 by year 10; 2803 by year 25). A healthcare payer perspective sensitivity analysis showed an ICER of $21,096.14/QALY. INTERPRETATION: These findings demonstrate that a suicide-prevention campaign in Ontario is very likely a cost-effective intervention to reduce the incidence of suicide and suggest suicide-prevention campaigns are likely to be cost effective for some other Canadian provinces and potentially other countries.

Epidemiology of Interpersonal Trauma among Women and Men Psychiatric Inpatients: A Population-Based Study.

OBJECTIVE: Small clinical samples suggest that psychiatric inpatients report a lifetime history of interpersonal trauma. Since past experiences of trauma may complicate prognosis and treatment trajectories, population-level knowledge is needed about its prevalence and correlates among inpatients. METHODS: Using health-administrative databases comprising all adult psychiatric inpatients in Ontario, Canada (2009 to 2016, n = 160,436, 49% women), we identified those who reported experiencing physical, sexual, and/or emotional trauma in their lifetime, 1 year, and 30 days preceding admission. We described the prevalence of each type of trauma, comparing women and men using modified Poisson regression, and identified individual-level characteristics associated with lifetime trauma history using multivariable logistic regression. RESULTS: 31.7% of inpatients reported experiencing trauma prior to admission. Lifetime prevalence was higher in women (39.6% vs. 24.1%; age-adjusted prevalence ratio [aPR] = 1.68; 95% CI, 1.65 to 1.71), including sexual (22.7% vs. 8.4%; aPR = 2.81; 95% CI, 2.73 to 2.89), emotional (33.3% vs. 19.4%; aPR = 1.76; 95% CI, 1.72 to 1.79), and physical trauma (24.2% vs. 14.8%; aPR = 1.68; 95% CI, 1.65 to 1.72). Factors most prominently associated with lifetime trauma were witnessing parental substance use (adjusted odds ratio [aOR] = 8.68; 95% CI, 8.39 to 8.99), female sex (aOR = 2.29; 95% CI, 2.23 to 2.35), and number of recent stressful life events (aOR = 1.62; 95% CI, 1.59 to 1.65). CONCLUSIONS: These results suggest that trauma-informed approaches are essential to consider in the design and delivery of inpatient psychiatric services for both women and men.

Risk of involuntary admission among first-generation ethnic minority groups with early psychosis: a retrospective cohort study using health administrative data.

AIMS: Ethnic minority groups often have more complex and aversive pathways to mental health care. However, large population-based studies are lacking, particularly regarding involuntary hospitalisation. We sought to examine the risk of involuntary admission among first-generation ethnic minority groups with early psychosis in Ontario, Canada. METHODS: Using health administrative data, we constructed a retrospective cohort (2009-2013) of people with first-onset non-affective psychotic disorder aged 16-35 years. This cohort was linked to immigration data to ascertain migrant status and country of birth. We identified the first involuntary admission within 2 years and compared the risk of involuntary admission for first-generation migrant groups to the general population. To control for the role of migrant status, we restricted the sample to first-generation migrants and examined differences by country of birth, comparing risk of involuntary admission among ethnic minority groups to a European reference. We further explored the role of migrant class by adjusting for immigrant vs refugee status within the migrant cohort. We also explored effect modification of migrant class by ethnic minority group. RESULTS: We identified 15 844 incident cases of psychotic disorder, of whom 19% (n = 3049) were first-generation migrants. Risk of involuntary admission was higher than the general population in five of seven ethnic minority groups. African and Caribbean migrants had the highest risk of involuntary admission (African: risk ratio (RR) = 1.52, 95% CI = 1.34-1.73; Caribbean: RR = 1.58, 95% CI = 1.37-1.82), and were the only groups where the elevated risk persisted when compared to the European reference group within the migrant cohort (African: RR = 1.24, 95% CI = 1.04-1.48; Caribbean: RR = 1.29, 95% CI = 1.07-1.56). Refugee status was independently associated with involuntary admission (RR = 1.16, 95% CI = 1.02-1.32); however, this risk varied by ethnic minority group, with Caribbean refugees having an elevated risk of involuntary admission compared with Caribbean immigrants (RR = 1.72, 95% CI = 1.15-2.58). CONCLUSIONS: Our findings are consistent with the international literature showing increased rates of involuntary admission among some ethnic minority groups with early psychosis. Interventions aimed at improving pathways to care could be targeted at these groups to reduce disparities.

Suicide and Self-Harm in Recent Immigrants in Ontario, Canada: A Population-Based Study.

OBJECTIVE: To estimate the rates of suicide and self-harm among recent immigrants and to determine which immigrant-specific risk factors are associated with these outcomes. METHODS: Population-based cohort study using linked health administrative data sets (2003 to 2017) in Ontario, Canada which included adults ≥18 years, living in Ontario (N = 9,055,079). The main exposure was immigrant status (long-term resident vs. recent immigrant). Immigrant-specific exposures included visa class and country of origin. Outcome measures were death by suicide or emergency department visit for self-harm. Cox proportional hazards estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). RESULTS: We included 590,289 recent immigrants and 8,464,790 long-term residents. Suicide rates were lower among immigrants (n = 130 suicides, 3.3/100,000) than long-term residents (n = 6,354 suicides, 11.8/100,000) with aHR 0.3, 95% CI, 0.2 to 0.3. Male-female ratios in suicide rates were attenuated in immigrants. Refugees had 2.1 (95% CI, 1.3 to 3.6; rate 6.1/100,000) and 2.8 (95% CI, 2.5 to 3.2) times the likelihood of suicide and self-harm, respectively, compared with nonrefugee immigrants. Self-harm rate was lower among immigrants (n = 2,256 events, 4.4/10,000) than long-term residents (n = 68,039 events, 9.7/10,000 person-years; aHR 0.3; 95% CI, 0.3 to 0.3). Unlike long-term residents, where low income was associated with high suicide rates, income was not associated with suicide among immigrants and there was an attenuated income gradient for self-harm. Country of origin-specific analyses showed wide ranges in suicide rates (1.4 to 9.9/100,000) and self-harm (1.8 to 14.9/10,000). CONCLUSION: Recent immigrants have lower rates of suicide and self-harm and different sociodemographic predictors compared with long-term residents. Analysis of contextual factors including immigrant class, origin, and destination should be considered for all immigrant suicide risk assessment.

Involuntary hospitalization among young people with early psychosis: A population-based study using health administrative data.

OBJECTIVE: Early psychosis is an important window for establishing long-term trajectories. Involuntary hospitalization during this period may impact subsequent service engagement in people with newly diagnosed psychotic disorder. However, population-based studies of involuntary hospitalization in early psychosis are lacking. We sought to estimate the proportion of people aged 16 to 35 years with early psychosis in Ontario who are hospitalized involuntarily at first admission, and to identify the associated risk factors and outcomes. METHODS: Using linked population-based health administrative data, we identified incident cases of non-affective psychosis over a five-year period (2009-2013) and followed cases for two years to ascertain the first psychiatric hospitalization. We used modified Poisson regression to model sociodemographic, clinical, and service-related risk factors, and compared service-related outcomes for cases admitted on an involuntary versus voluntary basis. RESULTS: Among 17,725 incident cases of non-affective psychosis, 38% were hospitalized within two years, and 81% of these admissions occurred on an involuntary basis (26% of cohort). Sociodemographic factors associated with an increased risk of involuntary admission included younger age (16-20), and first-generation migrant status. The strongest risk factors were poor illness insight, recent police involvement, and admission to a general (versus psychiatric) hospital. Outcomes associated with involuntary admission included increased likelihood of control intervention use and a shorter length of stay. CONCLUSIONS: One in four young people with first-episode psychosis will have an involuntary admission early in the course of their illness. Our findings highlight areas for intervention to improve pathways to care for people with psychotic disorder.

Trends in mental health service utilisation in immigrant youth in Ontario, Canada, 1996-2012: a population-based longitudinal cohort study.

OBJECTIVE: To describe trends in mental health service use of youth by immigration status and characteristics. DESIGN: Population-based longitudinal cohort study from 1996 to 2012 using linked health and administrative datasets. SETTING: Ontario, Canada. PARTICIPANTS: Youth 10-24 years, living in Ontario, Canada. EXPOSURE: The main exposure was immigration status (recent immigrants vs long-term residents). Secondary exposures were region of origin and refugee status. MAIN OUTCOME MEASURE: Mental health hospitalisations, emergency department (ED) visits and outpatient visits within consecutive 3-year time periods. Poisson regression models estimated rate ratios (RR). RESULTS: Over 2.5 million person years per period were included. Rates of recent immigrant mental health service utilisation were at least 40% lower than long-term residents (p<0.0001).Mental health hospitalisation and ED visit rates increased in long-term residents (hospitalisations, RR 1.09 (95% CI 1.08 to 1.09); ED visits, RR 1.15 (1.14 to 1.15)) and recent immigrants (hospitalisations RR 1.05 (1.03 to 1.07); ED visits, RR 1.08 (1.05 to 1.11)). Mental health outpatient visit rates increased in long-term residents (RR 1.03 (1.03 to 1.03)) but declined in recent immigrant (RR 0.94 (0.93 to 0.95)). Comparable divergent trends in acute care and outpatient service use were observed among refugees and across most regions of origin. Recent immigrant acute care use was driven by longer-term refugees (hospitalisations RR 1.12 (1.03 to 1.21); ED visits RR 1.11 (1.02 to 1.20)). CONCLUSIONS: Mental health service utilisation was lower among recent immigrants than long-term residents. While acute care use is increasing at a faster rate among long-term residents than recent immigrants, the decrease in outpatient mental health visits in immigrants highlights a potential emerging disparity in access to preventative care.

Trends in obesity and multimorbidity in Canada.

Very few studies have examined trends in multimorbidity over time and even fewer have examined trends over time across different body mass index (BMI) groups. Given a general decline in death rates but increased cardiovascular risk factors among individuals with obesity, the trend in the association between obesity and multimorbidity is hypothesized to be increasing over time. The data for our study came from the 1996-97 National Population Health Survey and the 2005 and 2012-13 Canadian Community Health Surveys (N = 277,366 across all 3 surveys). We examined trends in the association between BMI groups and multimorbidity using a logistic regression model. We also investigated trends in the prevalence of specific chronic conditions, pairs of chronic conditions and different levels of multimorbidity across BMI groups. We found significantly greater levels of multimorbidity in 2005 (OR = 1.42; p < 0.001) and 2012-13 (OR = 1.58; p < 0.001) relative to 1996-97. Changes in multimorbidity levels were much greater among individuals with class II/III (OR = 1.48; p = 0.005) and class I obesity (OR = 1.38; p = 0.001) in 2012-13 relative to 1996-97. Much of the increase in multimorbidity among individuals living with obesity was due to increases in 3+ chronic conditions and conditions in combination with hypertension, and the greatest increase was found among seniors living with obesity. Our results highlight the need for interventions aimed at preventing obesity and the prevention of chronic conditions among individuals with obesity, especially among seniors.

Mortality risk associated with psychological distress and major depression: A population-based cohort study.

BACKGROUND: Few studies have examined the impact of psychological distress on mortality. We aimed to estimate mortality rates of psychological distress and major depressive disorder (MDD) compared to a referent group with no MDD or psychological distress. METHODS: Our study population (N = 10 181) consisted of respondents from the Canadian Community Health Survey Cycle 1.2 linked to Ontario health administrative databases followed for up to 11 years. We used Cox proportional hazards models to assess overall, sex-specific, as well as short-term (within two years of follow-up) and long-term (follow-up ≥ two years) mortality among those with DSM-criteria MDD and psychological distress independent of MDD adjusted for socio-demographic, lifestyle and clinical factors. RESULTS: Individuals with psychological distress (n = 666) had a similar mortality rate as those with MDD (n = 428) and significantly greater adjusted hazards of death than the referent group (hazard ratio = 1.57, 95% CI = 1.14-2.15). The risk of death was greatest in the short-term among those with MDD, however, we observed a persistent 1.6-fold increased risk in both the short- and long-term among those with psychological distress compared to the referent. Women with MDD had the greatest mortality rate and died a median of 15 years earlier than women in the referent group. LIMITATIONS: Psychological distress and MDD were ascertained at baseline with small number of deaths in the early follow-up period. Survey variables were prone to self-report bias with a possibility of residual confounding. CONCLUSIONS: Focused longitudinal research and targeted management strategies for those with psychological distress and women with MDD are warranted.

Prevalence and predictors of involuntary psychiatric hospital admissions in Ontario, Canada: a population-based linked administrative database study.

BACKGROUND: Involuntary admissions to psychiatric hospitals are common; however, research examining the trends in prevalence over time and predictors is limited. Aims To examine trends in prevalence and risk factors for involuntary admissions in Ontario, Canada. METHOD: We conducted an analysis of all mental health bed admissions from 2009 to 2013 and assessed the association between patient sociodemographics, service utilisation, pathway to care and severity characteristics for involuntary admissions using a modified Poisson regression. RESULTS: We found a high and increasing prevalence of involuntary admissions (70.7% in 2009, 77.1% in 2013, 74.1% overall). Individuals with police contact in the prior week (risk ratio (RR) = 1.20) and immigrants both experienced greater likelihood of being involuntarily admitted, regardless of control for other characteristics (RR = 1.07) (both P < 0.0001). CONCLUSIONS: We identified numerous modifiable and non-modifiable risk factors for involuntary admissions. The prevalence of involuntary admissions was high, linearly increasing over time. Declaration of interest The authors have completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. This study was conducted using funding entirely from public sources. P.K. has received operational support via an Ontario Ministry of Health and Long-Term Care (MOHLTC) Health Services Research Fund Capacity Award to support this project. The Institute for Clinical Evaluative Sciences (ICES) is funded by the Ontario MOHLTC. The study results and conclusions are those of the authors, and should not be attributed to any of the funding agencies or sponsoring agencies. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. All decisions regarding study design, publication, and data analysis were made independent of the funding agencies.