Guest written by: David Miller
One of these things is not like the others:
Did you figure it out? I’ll give you a hint: this is obviously a trick made to emphasize what little regularity we attach to mental health assessment. You go to the doctor for regular check-ups or to receive specific treatments. Those guys at your local 30-minute oil change joint? You better believe they’ll have you in there regularly for your $25.99-that-ends-up-being-$54.26-after-the-“free”-wiper-blades oil change. These things are absolutes, at least to the extent that you’re expected to complete them with regularity or else face catastrophe.
Treatment for mental health issues is a total 180. We don’t go for regular checkups. We don’t always go even if we feel like we need treatment. Mental health treatment is kind of similar to the “dental model”, where we’re encouraged to go for check-ups but we really don’t bother until we end up with four cavities or we’re about to turn 25 and lose that sweet parentally-subsidized dental coverage. Thus, when we do go for mental health treatment, the band-aid fix doesn’t always work like it would for a cut or a bruise. Mental health treatment is not an absolute—there are a lot of factors at play that impact the illness trajectory, and the treatment outcomes associated with each individual and their respective difficulties. This leads to unpredictable service use, and more specifically in this case, readmission to inpatient psychiatric services. Readmission to inpatient treatment is an important phenomenon for a number of reasons, mainly due to the fact that inpatient care is super expensive (like 37% of the overall federal health budget for Canada in 2016—the largest portion), and research shows that some people (youth in particular) are better treated in the community through complementary support services, NOT through inpatient care.
So, why are youth being readmitted? What factors contribute to one youth needing repeated admissions for treatment, while another can make do with a single admission?
We decided to look into it. We did some research using provincial administrative data (in other words, data with every youth mental health admission to any New Brunswick hospital from 2003-2013), and our overall readmission stats were pretty consistent with existing research. About 27% of all youth ages 3-19 years old admitted in that time span had at least one readmission, with almost 50% of those readmissions occurring within 90 days of their discharge (aka, the “high-risk” period).
But, why are some youth being readmitted while others aren’t? Well, like I said, lots at play here. First off, some demographic stuff. Research shows that youth in rural areas tend to rely more heavily on inpatient services because of a lack of community care supports, which is partially tied to research that says youth from low socioeconomic (SES) households tend to exhibit more mental health issues. But hold up, because New Brunswick doesn’t fit that bill. Our research actually showed the opposite—youth from non-rural areas with a higher household SES were more likely to be readmitted within 90 days post-discharge. Does this mean we should celebrate the province of New Brunswick as the first ever province to better treat vulnerable populations in comparison to non-vulnerable? Sorry NB, but you’ll have to settle for the existing titles of world’s biggest lobster (you rock Shediac) and world’s biggest axe (in case the lobster gets out of control, smart thinking Nackawic). The issue is definitely more complex than that. What this really tells us is that youth from rural communities in lower SES households are probably more likely to have a difficult time actually obtaining care supports in general (inpatient care included). This could be due to a number of factors connected to rural, low SES living: parents’ erratic work hours, accessibility of services, access to transportation to use those services, financial means to pay for services—all things that may be a non-issue to non-rural, high-SES youth. Low-SES youth in rural areas may very well be “suffering in silence” in some cases. This is supported by looking at overall readmission rates long term, where all SES categories actually account for an equal amount of readmission from 1 year post discharge onward. So, low-SES youth in rural areas aren’t necessarily at a lower risk for readmission, it just takes them longer to get back to the hospital.
What about supportive factors? They absolutely play a role. Youth with a more supportive home environment both before, and after their inpatient stay are at a lower risk of being readmitted. This makes sense, because youth with mental health issues are going to cope with those issues better if they have a strong familial support system behind them. In line with that, we also found that youth who were referred to supportive aftercare services (as in, a clinician or counsellor) were less likely to be readmitted compared to youth who received a referral to typically less-supportive aftercare (as in, law enforcement). It’s really all about support—inpatient care is meant to stabilize a patient, so they can be discharged to community supports that can continue their treatment. If the support system isn’t in place before and following the admission, youths who aren’t sufficiently stabilized may need to return to inpatient care to further their treatment.
Picture baggage claim at the airport after most of the people take their bags. Someone has to pick up those last few bags, but they don’t, so the bags just keep going in and out, around the carousel. All those potential bag picker-uppers are service providers, and the bags are the youths that really need support to get them out of the loop.
And you may wonder, why bother bringing this up before talking about the impact of the diagnosis or treatment? Well, this isn’t like a broken leg. Because mental illnesses are so varied, and symptoms are so diverse (even within specific diagnoses), the impact of other demographic and support factors really play a role in the illness and treatment outcomes, especially when considering the various treatments for any given symptomology. That said, our research showed that youth with chronic mental illnesses (like psychosis) tended to have the highest likelihood of readmission among diagnoses, mainly because the illness requires long-term ongoing care. Also, youth with mood and affective disorders (like anxiety and depression) also had high rates of readmission, but this is partially due to the sheer volume of these cases—they commonly make up the largest portion of youth diagnoses in inpatient care, and in the context of NB, this is no different. Finally, youth with what we call ‘comorbid’ diagnoses (aka, multiple co-existing disorders) were more likely to be readmitted than those with single diagnoses. This is most likely due to the fact that comorbid diagnoses are typically more difficult to treat, given that you’re dealing with interacting symptoms and you may need multiple consultations with a number of different professionals. Overall, the diagnosis does play a role in the likelihood of a youth being readmitted, but we found that supportive and demographic factors predicted a larger amount of the variability in readmission.
What does this all mean? Well, it means we have some work to do to flesh out what exactly these results are telling us. Future research needs to more closely examine the relationship between different supportive factors and treatment outcomes, and we need to get a better idea of how geographic location and SES play into care-seeking behaviours. Policy-wise, these results point to a need for potential modified service delivery in rural areas, and an emphasis on post-discharge supports. Super easy, right?