A program aimed at improving access to mental health services for children and adolescents in Canada has shown substantial gains, a new study revealed.
The program, ACCESS Open Minds (ACCESS-OM), is based on five principles: Early identification, rapid access, appropriate care, no age-based transitions from 11 to 25 years, and youth and family engagement. The principles are flexible by design so that the program can be tailored to local factors. The program helped transform services at urban, rural, and Indigenous sites where it has been rolled out in Canada.
The findings were published online on February 26 in JAMA Psychiatry.
Measures of Success
The cohort study, which was led by Srividya N. Iyer, PhD, Canada Research Chair in Youth, Mental Health, and Learning Health Systems at McGill University in Montreal, included 4519 youths (ages 11-25 years) at 11 sites in Canada. Participants were referred between March 2016 and December 2020. The researchers evaluated the following three main factors to gauge the program’s effectiveness:
- Whether there were increases in the number of youths referred
- Whether more youths were offered evaluations within 72 hours of referral
- Whether youths received services within 30 days of the first appointment
The investigators found that each 6-month progression after the implementation of the program was associated with a 10% increase in referral rates. In addition, each 6-month progression was associated with a 3% decrease in time to offered evaluation and time to first services.
During year 1, the cumulative probability of being offered an appointment by 72 hours was 48%. This probability increased to 62% in year 2 and to 64% in year 3.
In the first year of the program, the cumulative probability of receiving services within 30 days was 85%. This probability increased slightly to 86% during year 2 and to 89% during year 3.
Patients with moderate to severe mental health problems, however, experienced 14% longer delays to offered first appointments and 11% longer wait times to services.
Reducing Wait Times
ACCESS-OM is a research network funded by the Canadian Institutes of Health Research and the Graham Boeckh Foundation to address gaps in access to mental health services for a diverse youth population.
Before this program, wait times countrywide for youth to access services typically ranged “from 45 days to a year and a half,” Iyer told Medscape Medical News. The only other option to avoid the wait was to go to an emergency department, she said.
The diversity in the cohort is essential in addressing mental health broadly in Canada and in making it scalable to other Canadian sites and other countries, Iyer said. The sites were in rural, urban, indigenous, remote, and English- and French-speaking areas.
The authors noted that lesbian; gay; bisexual; transgender; queer; intersex; Two-Spirit; Not in Education, Employment, or Training; racial and ethnic minority; and impoverished youths usually have trouble accessing mental health care. “Yet they constituted a substantial share of ACCESS-OM clientele, equaling or exceeding their proportions in the general population,” the authors wrote.
But the researchers found that primary and community settings may not be well equipped to treat more severe mental health problems, and that situation resulted in longer wait times for that group. Future research should address this question, Iyer said.
Youth and families helped design the ACCESS-OM program. “All clinicians who were working at these access sites were hired by committees that involved young people,” Iyer said.
Clearing the Bottlenecks
The program also used an open referral system that enabled young people to be referred by family members, counselors, or teachers. Young people also can request services for themselves. The first person the youths see, for the purpose of gathering a history, is not a psychiatrist. This arrangement eases the burden on specialists, of whom there is a shortage, Iyer said. “There’s plenty of evidence that other professionals with some training can do this job very well. That was a very important ingredient.”
The programs are also funded through the public health system in Canada. This funding may play a key part in the program’s success, said Iyer, but it may make the program less generalizable to countries without universal healthcare.
Louise Gallagher, MB, PhD, chief of the Child and Youth Mental Health Collaborative at the Hospital for Sick Children in Toronto and professor of psychiatry at the University of Toronto, Toronto, told Medscape Medical News that she was struck that the probability of being offered an appointment by 72 hours jumped from 48% to 64% from years 1 to 3. That’s critical, she said, because “when they’re ready to engage, you need to catch them at that moment.”
The small increase in receiving timely services reflects a widely observed lack of resources to evaluate youth and provide the services quickly, Gallagher added.
Open referrals are particularly important, she said, because with the shortage of primary care providers in Canada, requiring referrals to a psychiatrist to come from primary care providers is not practical.
The longer wait times for youth with moderate to severe mental health needs should also trigger further targeted research to find out where the gaps are, Gallagher said. “The challenge for the model is how to ensure that you have any specialist you need for any youth who shows up at your door needing services.”
ACCESS-OM is funded by the Canadian Institutes for Health Research and the Graham Boeckh Foundation. Iyer and Gallagher reported having no relevant financial relationships.
Marcia Frellick is an independent healthcare journalist based in Chicago.
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