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ICES study finds highly educated Ontarians have better access to psychiatric care


Psychiatric care in Ontario is fully covered by provincial health insurance. But a study out of the Institute for Clinical Evaluative Sciences (ICES) has found highly educated Ontarians are more likely to get referred to a psychiatrist than their less-educated counterparts.

The study used physician claims and census data from 1995 to 2004 and followed 1.5 million adults in Toronto who had not had a mental health visit in the previous three years. The study found:

  • Once seen by a family doctor for a mental health visit, people from higher education neighbourhoods were 30% more likely to be referred to a psychiatrist. Women from higher education neighbourhoods were also referred for psychiatric care three months faster than women from lower education neighbourhoods.
  • More than one-third of people who saw a psychiatrist did so without a prior mental health visit to a family doctor. In other words, they bypassed the gatekeeper system.
  • Compared to those with the lowest levels of education, highly educated Ontarians were more than twice as likely to bypass the gatekeeper system, and saw psychiatrists three to six months faster than low education people who had also bypassed the system.
  • Those in the highest education neighbourhood who bypassed the gatekeeper system had their first mental health visit 10 months earlier than those in the lowest education neighbourhood who did not bypass the gatekeeper system.

“A significant portion of psychiatric service users find ways to directly access psychiatric care without being referred by their family doctors. This gets them specialty care faster. The worry is that the people who are most likely to be able to navigate the system in this way are the people who are least likely to need fast access to a specialist. The socially disadvantaged groups who need more help, more quickly – are getting less help and slowly” says lead researcher Leah Steele.

In Ontario, psychiatric care is fully covered by provincial health insurance. There are no limits to the number of visits you can have to a psychiatrist or family doctor for mental healthcare. The system that we have in Ontario supports a “gatekeeper” function of the family doctor by paying psychiatrists more for consultations with patients who have a physician referral.

Despite universal healthcare coverage in Ontario there is evidence of inequity in referral patterns and referral times. The new models of primary healthcare which encourage collaborative care for mental health might help to improve access to care for those who don’t bypass their family physicians. “System changes that emphasize shared care and collaborative care between family doctors and psychiatrists are an important policy direction to improve access to psychiatric care for everybody. However, these broad changes will not address socioeconomic disparities. We need targeted programs to low literacy, socially disadvantaged people, as well as outreach and mental health literacy programs,” say Steele.

Author affiliations: ICES (Steele, Glazier, Moineddin); Department of Family and Community Medicine, UofT and St. Michael’s Hospital (Steele, Glazier, Moineddin); Centre for Research on Inner City Health (Steele, Glazier, Agha), Dalla Lana School of Public Health, UofT (Glazier, Moineddin, Agha) Centre for Addition and Mental Health (Steele).

The study “The gate-keeper system and disparities in use of psychiatric care by neighbourhood education level: results of a nine year cohort study in Toronto” is in the May 15, 2009 issue of Healthcare Policy.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.


Read the Journal Article