Barriers to Outpatient Care among Emergency Department Users with Mental Disorders - a Profile and a Mixed Methods Study

Introduction: The prevalence and associated social and economic burden of patients with mental disorders (MD) has resulted in a Canadian public health crisis. Despite the efforts of recent healthcare reforms, a significant portion of patients with MD continue to rely heavily on emergency departments (ED) for care. This is particularly concerning as the ED is not equipped to address psychosocial needs or provide follow-up care. ED users with MD, especially high ED users with MD, are more likely to be socially and materially deprived, have more concurrent disorders, have higher rehospitalization rates, and overall high service use compared to those who present to the ED for other conditions or reasons. This suggests that ED users with MD may perceive unique barriers to care and unmet needs. However, previous studies have mostly evaluated “having or not having” unmet needs without examining the number or types of structural and motivational barriers to care. Additionally, few profile studies have been conducted on high ED users with MD, and none to our knowledge have been related to barriers to care. Objectives: The purpose of this thesis was to investigate perceived unmet needs of ED users with MD and especially structural and motivational barriers to care of high ED users to better understand psychiatric ED use and recommend more targeted interventions to improve outpatient care. This thesis had two objectives: (1) to identify ED service use profiles based on the patients’ perceived barriers to care and associate these ED profiles with their sociodemographic and clinical characteristics and (2) to assess the associated patient characteristics and service use patterns in addition to the structural and motivational barriers to care that could explain high ED use among patients with MD. Methods: Data was extracted from a 2021-2022 survey and medical records of ED users with MD in large psychiatric ED networks in Quebec. For the first study, cluster algorithms and comparison tests identified three ED user profiles based on the patients’ perceived barriers to outpatient care and service use. For the second study, a mixed methods approach (multivariable regression, content analysis) identified variables associated with the number of perceived unmet care needs, and structural and motivational barriers to care explaining high ED use. Results: The first article identified three distinct profiles and found the subgroup that perceived the most barriers to care were often high ED users with lower service satisfaction and having worse perceived mental/health conditions. In the second article, high ED users dissatisfied with services and perceiving more health issues (except suicidal behavior) had more barriers to care. Overall patients with no perceived unmet needs were more satisfied with outpatient care. High ED users with high unmet needs found healthcare providers didn’t take them seriously enough, whereas patients with no unmet needs were rarely dissatisfied, except in the case of addiction treatment centers. Moreover, patients with suicidal behaviors said they felt less stigmatized and that healthcare providers took their concerns more seriously. Additionally, high ED users with high unmet needs were found to perceive more barriers to care than those with no unmet needs, especially in terms of accessibility, continuity and adequacy of care. Outpatient services were often deemed unreliable, and patients were mostly referred to the ED due to doctors’ inexperience with crises and care inconsistency. Conclusions: The study findings suggested several recommendations to improve the quality of outpatient services and better address the perceived unmet needs of ED users with MD. These strategies include improving access, coordination and continuity of mental health care, and increasing patient knowledge of mental health and addiction services. This encompasses implementing more crisis teams and home treatment teams, intensive case management, brief interventions and peer support

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