Leah S. Steele

Using administrative data to measure ambulatory mental health service provision in primary care.

Objective:We sought to determine the accuracy of administrative data for identifying mental health service provision in primary care. Study Design:This was a chart abstraction study measuring agreement between billing data and clinical data on the binary variable “mental health visit.” Data were collected from the charts and billing records of 5 academic family practice clinics in Toronto, Ontario (1999 to 2000). Billing claims (n = 952) were selected from the billings for all visits by a stratified random sampling technique. A blinded data abstractor reviewed the clinical charts and assigned diagnostic codes for each patient visit associated with the selected claims. Any visit with at least 1 abstracted mental health diagnostic code was defined as a mental health visit. The test characteristics of 4 administrative measures of mental health service provision, based on different combinations of billing codes, were calculated. Results:The accuracy of the administrative data was 86.8% when compared with clinical data. The sensitivity of the 4 administrative measures ranged from 22.3% to 80.7%. The specificity ranged from 97.0% to 99.5%. Conclusions:This is the first study to establish the performance of administrative data in measuring mental health service provision in a primary care setting. In our setting, broadly defined administrative measures of mental health have excellent specificity and adequate sensitivity for exploring and understanding mental health service utilization.

Women's Sexual Orientation and Health: Results from a Canadian Population-Based Survey

The current study sought to determine whether health status and health risk behaviors of Canadian women varied based on sexual identity. This was a cross-sectional analysis of data from the Canadian Community Health Survey: cycle 2.1, a national population-based survey designed to gather health data on a representative sample of over 135,000 Canadians including 354 lesbian respondents, 424 bisexual women respondents, and 60,937 heterosexual women respondents. Sexual orientation was associated with disparities in health status and health risk behaviors for lesbian and bisexual women in Canada. Bisexual women were more likely than lesbians or heterosexual women to report poor or fair mental and physical health, mood or anxiety disorders, lifetime STD diagnosis, and, most markedly, life-time suicidality. Lesbians and bisexual women were also more likely to report daily smoking and risky drinking than heterosexual women. In sum, sexual orientation was associated with health status in Canada. Bisexual women, in particular, reported poorer health outcomes than lesbian or heterosexual women, indicating this group may be an appropriate target for specific health promotion interventions.

Socioeconomic status and self-reported barriers to mental health service use.

Objective: Socially disadvantaged individuals are at high risk for having their mental health service needs unmet. We explored the relations among education level, income level, and self-reported barriers to mental health service use for individuals with a mental illness, using data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Methods: Our sample group comprised the 8.3% of adult respondents who met the CCHS 1.2 criteria for an anxiety or affective disorder in the past 12 months (n = 3101). We examined the association between education and income levels and self-reported accessibility, availability, or acceptability barriers to mental health care. Results: Accessibility, availability, and acceptability barriers were reported by 3%, 5%, and 16% of our sample, respectively. Individuals with a high school diploma were less likely than individuals without a high school diploma to report acceptability barriers to care (odds ratio 0.65; 95% confidence interval, 0.45 to 0.93). Higher-income individuals were less likely than lower-income individuals to report acceptability barriers to care (odds ratio 0.69; 95% confidence interval, 0.50 to 0.96). Employment, distress level, age, and family structure were also associated with acceptability barriers. Conclusion: Issues related to acceptability explain most of the unmet need for mental health services. Program planners should consider the development of targeted approaches to service delivery and outreach for low-income, working individuals who have not completed high school.

Geographic Methods for Understanding and Responding to Disparities in Mammography Use in Toronto, Canada

OBJECTIVE: To use spatial and epidemiologic analyses to understand disparities in mammaography use and to formulate interventions to increase its uptake in low-income, high-recent immigration areas in Toronto, Canada.DESIGN: We compared mammography rates in four income-immigration census tract groups. Data were obtained from the 1996 Canadian census and 2000 physician billing claims. Risk ratios, linear regression, multilayer maps, and spatial analysis were used to examine utilization by area for women age 45 to 64 years.SETTING: Residential population of inner city Toronto, Canada, with a 1996 population of 780,000.PARTICIPANTS: Women age 45 to 64 residing in Toronto’s inner city in the year 2000.MEASUREMENTS AND MAIN RESULTS: Among 113,762 women age 45 to 64, 27,435 (24%) had received a mammogram during 2000 and 91,542 (80%) had seen a physician. Only 21% of women had a mammogram in the least advantaged group (low income-high immigration), compared with 27% in the most advantaged group (high income-low immigration) (risk ratio, 0.79; 95% confidence interval, 0.75 to 0.84). Multilayer maps demonstrated a low income-high immigration band running through Toronto’s inner city and low mammography rates within that band. There was substantial geographic clustering of study variables.CONCLUSIONS: We found marked variation in mammography rates by area, with the lowest rates associated with low income and high immigration. Spatial patterns identified areas with low mammography and low physician visit rates appropriate for outreach and public education interventions. We also identified areas with low mammography and high physician visit rates appropriate for interventions targeted at physicians.

Service Use and Gaps in Services for Lesbian and Bisexual Women During Donor Insemination, Pregnancy, and the Postpartum Period

OBJECTIVE Increasing numbers of lesbian and bisexual women are choosing to have children. This qualitative study investigated the degree to which a sample of Canadian lesbian and bisexual women were satisfied with the health and social services that they received during the process of trying to conceive, during pregnancy, and during the early postpartum weeks and months. METHODS Three focus groups were conducted: (1) women who were themselves, or whose partners were, in the process of trying to conceive (n = 6); (2) biological parents of young children (n = 7); and (3) women who were non-biological parents of young children or whose partners were currently pregnant (n = 10). Participants were asked to discuss their positive and negative experiences with health and social services during their efforts to conceive and through the perinatal period. RESULTS Participants were very satisfied with the care they received from midwives, doulas, and public health nurses. Services directed specifically to lesbian, gay, and bisexual parents were also perceived to be important sources of information and support. Many participants perceived fertility services to be unsupportive or unable to address their different health care needs. CONCLUSION Participants expressed satisfaction with pregnancy-related services provided by non-physicians and dissatisfaction with services provided by physicians and fertility clinics. There is a strong desire for fertility services specific to lesbian and bisexual women, but even minor changes to existing services could improve the satisfaction of lesbian and bisexual patients.

“I Don't Want to Turn Totally Invisible”: Mental Health, Stressors, and Supports among Bisexual Women during the Perinatal Period

Almost no research has examined the parenting experiences of bisexual people. In this mixed-methods study, sexual minority women (N = 64) who were currently trying to conceive, pregnant, or parenting an infant completed standardized questionnaires to assess mental health, social support, and other variables. Fourteen participants identified as bisexual, and 14 reported sexual activity with men in the past 5 years (there was incomplete overlap between these groups). Twenty women (5 bisexual-identified) also completed a qualitative interview. Bisexual women reported poorer scores on assessments of mental health, substance use, social support, and experiences of perceived discrimination, relative to other women in the sample. Differences were particularly pronounced for women who reported sexual activity with men in the past 5 years compared to women who did not. Qualitative analyses highlighted experiences of invisibility and exclusion. It may be particularly challenging for bisexual women to negotiate the invisibility associated with a bisexual identity during the perinatal period, as a result of the implicit assumption that mothers are heterosexual. This invisibility may be linked with a multitude of poor outcomes that could have implications for the mother, baby, and family.

Predictors of Opioid-Related Death During Methadone Therapy.

We aimed to examine pharmacologic, demographic and medical comorbidity risk factors for opioid-related mortality among patients currently receiving methadone for an opioid use disorder. We conducted a population-based, nested case-control study linking healthcare and coroners records in Ontario, Canada, from January 31, 1994 to December 31, 2010. We included social assistance recipients receiving methadone for an opioid use disorder. Within this group, cases were those who died of opioid-related causes. For each case, we identified up to 5 controls matched on calendar quarter. The primary analysis examined the association between use of psychotropic drugs (benzodiazepines, antidepressants or antipsychotics) and opioid-related mortality. Secondary analyses examined the associations between baseline characteristics, health service utilization, comorbidities and opioid-related mortality. Among 43,545 patients receiving methadone for an opioid use disorder, we identified 175 (0.4%) opioid-related deaths, along with 873 matched controls. Psychotropic drug use was associated with a two fold increased risk of opioid-related death (adjusted odds ratio (OR) 2.0; 95% confidence interval (CI) 1.2 to 3.5). Specifically, benzodiazepines (adjusted OR 1.6; 95% CI 1.1 to 2.5) and antipsychotics (adjusted OR 2.3; 95% CI 1.5 to 3.5) were independently associated with opioid-related death. Other associated factors included chronic lung disease (adjusted OR 1.7; 95% CI 1.2 to 2.6), an alcohol use disorder (adjusted OR 1.9; 95% CI 1.2 to 3.2), mood disorders (adjusted OR 1.8; 95% CI 1.0 to 3.2), and a history of heart disease (adjusted OR 5.3; 95% CI 2.0 to 14.0). Psychotropic drug use is associated with opioid-related death in patients receiving methadone. Mindfulness of these factors may reduce the risk of death among methadone recipients.

Sexual and Gender Minority Peoples' Recommendations for Assisted Human Reproduction Services

OBJECTIVE To determine what recommendations lesbian, gay, bisexual, trans, and queer (LGBTQ) people have for provision of assisted human reproduction (AHR) services to their communities. METHODS Using a semi-structured guide, we interviewed a purposeful sample of 66 LGBTQ-identified individuals from across the province of Ontario who had used or had considered using AHR services since 2007. RESULTS Participants were predominantly cisgender (non-trans), white, same-sex partnered, urban women with relatively high levels of education and income. Participants made recommendations for changes to the following aspects of AHR service provision: (1) access to LGBTQ-relevant information, (2) adoption of patient-centred practices by AHR service providers, (3) training and education of service providers regarding LGBTQ issues and needs, (4) increased visibility of LGBTQ people in clinic environments, and (5) attention to service gaps of particular concern to LGBTQ people. CONCLUSION Many of the recommendations made by study participants show how patient-centred models may address inequities in service delivery for LGBTQ people and for other patients who may have particular AHR service needs. Our results suggest that service providers need education to enact these patient-centred practices and to deliver equitable care to LGBTQ patients.

Correlates of Mental Health Service Use Among Lesbian, Gay, and Bisexual Mothers and Prospective Mothers

ABSTRACT Lesbian, gay, and bisexual women undertake parenting in a social context that may be associated with unique risk factors for perinatal depression. This cross-sectional study aimed to describe the mental health services used by women in the perinatal period and to identify potential correlates of mental health service use. Sixty-four women who were currently trying to conceive, pregnant, or the parent of a child less than one year of age were included. One-third of women reported some mental health service use within the past year; 30.6% of women reported a perceived unmet need for mental health services in the past year, with 40% of these women citing financial barriers as the reason for their unmet need. Women who were trying to get pregnant or who were less “out” were most likely to have had recent mental health service use. Women who had conceived by having sex with a man or who reported more than three episodes of discrimination were most likely to report unmet needs for mental health services. Providers may benefit from additional knowledge about the LBG social context that is relevant to perinatal health, and from identifying a strong referral network of skilled and affordable counsellors.

Examining the relationship between neighbourhood deprivation and mental health service use of immigrants in Ontario, Canada: a cross-sectional study

Objective While newcomers are often disproportionately concentrated in disadvantaged areas, little attention is given to the effects of immigrants’ postimmigration context on their mental health and care use. Intersectionality theory suggests that understanding the full impact of disadvantage requires considering the effects of interacting factors. This study assessed the inter-relationship between recent immigration status, living in deprived areas and service use for non-psychotic mental health disorders. Study design Matched population-based cross-sectional study. Setting Ontario, Canada, where healthcare use data for 1999–2012 were linked to immigration data and area-based material deprivation scores. Participants Immigrants in urban Ontario, and their age-matched and sex-matched long-term residents (a group of Canadian-born or long-term immigrants, n=501 417 pairs). Primary and secondary outcome measures For immigrants and matched long-term residents, contact with primary care, psychiatric care and hospital care (emergency department visits or inpatient admissions) for non-psychotic mental health disorders was followed for 5 years and examined using conditional logistic regression models. Intersectionality was investigated by including a material deprivation quintile by immigrant status (immigrant vs long-term resident) interaction. Results Recent immigrants in urban Ontario were more likely than long-term residents to live in most deprived quintiles (immigrants—males: 22.8%, females: 22.3%; long-term residents—both sexes: 13.1%, p<0.001). Living in more deprived circumstances was associated with greater use of mental health services, but increases were smaller for immigrants than for long-term residents. Immigrants used less mental health services than long-term residents. Conclusions This study adds to existing research by suggesting that immigrant status and deprivation have a combined effect on recent immigrants’ care use for non-psychotic mental health disorders. In settings where immigrants are over-represented in deprived areas, policymakers focused on increasing immigrants’ access of mental health services should broadly address the influence of structural and cultural factors beyond the disadvantage.