Improving mental health outcomes for children and youth in Nova Scotia.
We are currently developing a program of outcomes research in conjunction with the Mental Health & Addictions program at the IWK Health Centre. Outcomes research brings experts together from various disciplines and backgrounds to improve care for patients and families with patients and families. Our research aims to guide policy and planning, while providing insight about making care more effective, timely and patient-centered.
Current Research Projects
Opening the Door
Child and adolescent use of the emergency department (ED) for mental health concerns has been steadily increasing compared to other illnesses. The objectives of Opening the Door we are 1) Inform our research questions (i.e. Why are young patients and their families increasingly using the ED for mental and behavioural disorders?) for our program of research 2) Develop and evaluate interventions to improve outcomes following ED visits and 3) Develop and evaluate quality indicators for ongoing monitoring and improvement of ED mental health care across several domains. A main goal of the project is to achieve these objectives through engaging patients and families who have used the IWK ED to better understand the increased use of the ED for mental health concerns. In doing this, patient and families perspectives can be used to guide future research projects and contextualize findings.
In Through the Out Door: Do Increasing Pediatric Emergency Mental Health Presentations Reflect Poorer Access to Primary and Outpatient Mental Health Care?
As many as one in five Canadian children and youth experience mental illness. Unfortunately, many do not receive the care they require to treat their mental illness, perhaps because they can’t get timely care from a family doctor or from community mental health services. Lack of proper treatment can have long-lasting harmful effects on their mental and physical health, education, and employment. It can also leave children and young people at risk of mental health crises. Recent reports show that many Canadian children and young people are increasingly turning to hospital Emergency Departments for help with mental illnesses. However, Emergency Departments are designed for very quick assessments and care of trauma or other emergencies and are not well-suited for the kind of wide-ranging, ongoing care necessary for the proper assessment and treatment of mental illnesses. In this study, we will measure how many children and youth in Nova Scotia are going to the IWK Emergency Department for mental and behavioural disorders. We will also study whether these visits are related to not having a regular family doctor, or are the result of long wait times to be seen in outpatient mental health clinics. This will help us to identify opportunities to support family doctors and mental health services to reduce the need for use of Emergency Departments for mental health care. We will compare the use of the IWK Emergency Department in different communities to help us identify areas of higher and lower than average use in which we should focus our attention, both to see what is not working in mental health care, and what is working well.
Electronic Routine Outcome Measurement in Child and Adolescent Community Mental Health Clinics: Implementing Outcome-Informed Care
When patients and families are seen by the IWK's Mental Health and Addictions Program, they complete a paper and pencil questionnaire that asks about their emotions, behaviours, hyperactivity or inattention, peer relationships, and prosocial behaviours. They are also asked what (if any) impact these have had on their home life, friendships, classroom learning, leisure activities and the family as a whole. This questionnaire, the Strengths and Difficulties Questionnaire or “SDQ”, is brief (25 questions) but gives patients, families and clinical staff (such as Psychologists and Social Workers) a reliable picture of how well the child or young person is functioning in important areas in their life. This information is particularly useful in a clinical setting, as it provides valuable insight into how well (or not well) treatment is working. However, when the questionnaire is filled out on paper, the patient has long left the clinic before it can be scored or made available to their clinician. Therefore, we would like to introduce an iPad version of the questionnaire into the Community Mental Health Clinics. As the patient and their family fill out the SDQ on an iPad it is automatically entered into a database, scored, and made available for their clinician to use during their appointment. This is known as Routine Outcome Measurement (“ROM”). It will also offer the opportunity to monitor patients’ personal treatment goals. Research indicates that ROM improves patients’ outcomes, reduces unnecessary treatments, shorten length of treatment, and improves satisfaction with mental health services.
Maternal Obesity and Offspring Mental Health
Pre-pregnancy obesity has been shown to have negative consequences on various infant health outcomes. Recent studies have reported that pre-pregnancy obesity increases the risk of impaired cognitive performance, autism spectrum disorder, negative emotionality, and symptoms of attention-deficit hyperactivity disorder (ADHD) in school-aged children. Understanding the association between maternal obesity and developmental and mental disorders among offspring is important given that as many as one in five children are affected by these disorders by the age of 15. A better ability to understand this association is also key to informing effective interventions. We recently conducted an analysis using data from the Nova Scotia Atlee Perinatal Database (NSAPD) between 2005 and 2016, in which we demonstrated that children of mothers who are obese have more visits to a physician for common childhood mental disorders. However, our conclusions were limited by the inability to adequately assess the contribution of a key confounder - maternal mental illness. The NSAPD contains minimal information on maternal mental health; data capture is limited to current psychiatric medication use and identification of psychiatric illness in the perinatal health record. We are unsure with how this information aligns with other measures of maternal mental health, such as health care utilization information for mental health conditions. The NSAPD has other limitations, such as the lack of detailed sociodemographic information on the mothers.There are individual databases spanning a wealth of clinical, social, economic, and health service use information already existing in Nova Scotia. Alone, they are not able to address the complex questions faced in understanding this relationship. Therefore, we propose to link several existing databases to create an anonymous database (a “cohort”) of all children born in Nova Scotia between 2005 and 2016 that will have rich information about mothers’ BMI, mental health, and social and economic factors (such as income, education, rural residence). The cohort will allow us to pose research questions that will improve our understanding of the effects of mothers’ characteristics on children’s health outcomes. We will demonstrate the ability of the cohort to answer such questions by means of a test case analysis of maternal obesity and offspring mental health, while assessing the contribution of a key potential confounder, maternal mental illness.
Transforming Care in Nova Scotia: Implementation of Health System Change in Child and Adolescent Mental Health and Addictions
This research addresses the mental health and addictions and models of health human resources priorities of the Nova Scotia Health Research Foundation and the Nova Scotia Department of Health and Wellness. The creation of an accountable mental health care system centred on recovery for patients and families is a leading priority for health system transformation in Nova Scotia. This requires a major shift in the philosophy and organization of health care to replace a traditional system that is largely “clinician as the expert, patient as the help seeker”, with little ability to measure patient-centred outcomes, tailor care, or actively engage patients and families in the care process. Efforts are under way in Nova Scotia to transform primary care, mental health and addictions services, and home care. Selected to guide transformation of child and adolescent mental health and addictions services, the Choice and Partnership Approach (CAPA) is a mental health and addictions service transformation model that combines collaborative and participatory practice to enhance effectiveness, leadership, skills modelling, and demand and capacity management. CAPA was developed in the United Kingdom and has been implemented across child and adult mental health and addictions program areas in parts of Europe, Australia, New Zealand and Canada, but has not been comprehensively evaluated for impact on system and patient outcomes. While CAPA has been implemented to varying degrees across child and adolescent mental health and addictions services in Nova Scotia, progress has been slower than desired, and achieving ‘scale-up’ has proven problematic. Ongoing implementation of CAPA in Nova Scotia serves as an excellent opportunity to rigorously study the scale-up of a transformative model of mental health and addictions care across variably resourced jurisdictions while maintaining fidelity to the care model. We will use realist evaluation methods to describe “To what degree does CAPA work in Nova Scotia, for whom, and under what circumstances?”. We will engage patients and families, clinicians, administrators, and decision makers to identify outcomes, mechanisms, and contexts that inform our understanding of facilitators and barriers to the implementation of the CAPA transformational model of child and adolescent mental health services. This knowledge, together with the methods and relationships cultivated through this study, will serve as the foundation for a broader program of research aimed at understanding the conditions and processes needed to achieve transformational systemic change in other jurisdictions and for other areas of health care in Nova Scotia, including primary care and home care.