Immigrant, refugee youth most likely to visit the ED with a new mental health problem

Refugee and immigrant youth in Ontario may face barriers to accessing mental health services through primary care, say the authors of a study of emergency department visits published in CMAJ (Canadian Medical Association Journal).

The study looked at emergency department visits for mental health issues or self-inflicted harm by youth between the ages of 10 and 24 years in Ontario. There were 118,851 youth who visited an emergency department with a mental health concern during the five-year study period (2010-2014), of whom 1.8% (2194) were refugees and 5.6% (6680) were non-refugee immigrants. For many of these youth, their emergency department visit was their first physician contact for mental health services. Rather than presenting first to primary care, 61.3% of refugee youth, 57.6% of non-refugee immigrants and 51.3% of non-immigrant youth presented to the emergency department with a mental health crisis.

Among immigrants, newcomers (fewer than five years in Canada) and refugees had the highest rates of first contact in the emergency department. Having a family doctor who practised as part of a team (versus a walk-in clinic model of care) was associated with better rates of receiving outpatient mental health care prior to presenting in crisis to the emergency department.

"Our study highlights that immigrants face barriers to using mental health services from a physician on an out-patient basis, but there is variability within immigrant groups by country and region of origin as well as by duration of residence in Canada," says Dr. Natasha Saunders, Department of Pediatrics, The Hospital for Sick Children (SickKids) and ICES.

"The results are consistent with those of other studies of adults that show immigrants and refugees may not have the same access to mental health services by physicians in the community compared with non-immigrants," she says.

"The findings suggest a need to understand the barriers and enabling factors that contribute to the use of mental health services and access to care, including focusing efforts to reduce stigma and identify mental health problems early, before crises. This is particularly important for refugee and newcomer youth and immigrants from Africa and Central America where we saw the highest rates of first contact in the emergency department," say the authors.

In a related commentary, Dr. David Cawthorpe, Alberta Children's Hospital Research Institute, University of Calgary, writes "What is clear from this study, however, is that first presentation with a mental health issue to the emergency department is common for all youth in Ontario, which signals general problems with access to appropriate mental health services in the province."

"There is no question that marginal groups may be overrepresented at the gateways to service, and it is necessary to understand and address the contributing factors. Nevertheless, failing to grasp the overarching issues, such as the lack of integration and organization of health and mental health services, will perpetuate current barriers to access and treatment. Youth mental health resources remain the orphan's orphan—segregated and scarce—and proven fledging innovations directed at shaping access to appropriate services require wider dissemination," he argues.

"Use of the emergency department as a first point of contact for mental health care by immigrant youth in Canada: a population-based study" is published October 9, 2018.