Determinants of Self-referral Pathways to Youth Mental Health Services and Their Impact on Timely Access to Care

Aims: The traditional youth mental health system has been criticized for being inaccessible and complicated, with youth making multiple stops before receiving care. ACCESS Open Minds (ACCESS), a services research project, developed, implemented, and evaluated a transformation of youth mental health services at 14 sites across Canada. Unlike the traditional system, ACCESS allowed youth to refer themselves (self-referral). Self-referral has been theorized to shorten treatment delays, especially for traditionally underserved youth. Questions remain about which youth self-refer and if it impacts wait times to mental health services. This study aims to compare: (1) socio-demographic and clinical characteristics associated with self-referral versus other referral routes among help-seeking youth at ACCESS sites; (2) wait times to first appointment for those self-referring versus using other routes. We hypothesized that self-referral would be associated with shorter wait times to first appointment. Methods: Data on sociodemographic, clinical, referral pathways, and service use factors were collected via records, self-report forms, and clinical interviews. Eleven of the fourteen sites were included in analyses; excluded sites were either not part of the cohort study (n=2) or did not collect data on key outcomes (n=1). Multiple logistic regression and an accelerated failure time model, both with multilevel modeling, were used to investigate the first and second aim, respectively. Multivariate Imputation by Chained Equations models were used to handle missingness. Results: The analytic sample included 4,421 youth; 39% were self-referred and 61% arrived via other referral pathways. The odds of self-referral were higher for each increasing year of age (OR:1.10, 95% CI:1.06-1.14), for those who did not have a secondary diploma, compared to those who were too young to have a secondary diploma (OR:1.42, 95% CI:1.02-1.98); for those who had previously been assessed at ACCESS sites, compared to those with no previous service seeking (OR:2.28, 95% CI:1.61-3.24), and for each 6 month increase in time since ACCESS implementation (OR:1.09, 95% CI:1.05-1.14). Conversely, sexual minority youth (OR:0.81, 95% CI:0.67-0.98) and those with moderate-to-significant difficulties with functioning (OR:0.81, 95% CI:0.65-0.99) were less likely to self-refer. Self-referral was not associated with gender, ethnic or cultural origins, engagement in education, employment, or training, presence of a reliable adult, mental health problem severity, or coming in before or after the start of the COVID-19 pandemic. Controlling for these socio-demographic, clinical, and service use factors, self-referral was associated with decreased time (in days) from referral to first appointment (TR:0.70, 95% CI:0.65-0.76). Explanatory analyses showed that the increased time to first appointment for those referred by others is attributable to the time needed to first contact the referral source and then the youth to offer an appointment. Conclusions: The notable uptake of self-referral and its impact on increasing timeliness of access to care suggest that self-referral should remain a feature of youth mental health service reform. However, this pathway was used differentially by youth based on certain characteristics, which may contribute to disparities in timely access to care. Future work should promote self-referral, particularly among those less likely to use it, while reducing delays to appointments for youth referred by others

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