Abstract
Adolescents with severe mental illness often age out of pediatric care without a clear transfer of care to adult services. The extent to which primary care provides stability during this vulnerable transition period is not known. To analyze the association between primary care continuity during the transition from pediatric to adult care and need for acute mental health services in young adulthood. This population-based cohort study used linked health and demographic administrative data for all adolescents aged 12 to 16 years with severe mental illness ascertained by hospitalization for schizophrenia, eating disorder, or mood disorder between April 1, 2002, and April 1, 2014, in Ontario, Canada. Participants were followed up through March 31, 2017. Data were analyzed from July 2018 to January 2019. Continuous primary care (same physician as baseline [age 12-16 years] always or sometimes), discontinuous primary care (visits to a primary care physician during the transition period who was not the patient's usual physician), and no primary care during the transition period (age 17-18 years). Mental health-related hospitalizations and emergency department visits in young adulthood (age 19-26 years) adjusted for sex, rurality, neighborhood income, mental illness type, and health service use before transition. Among 8409 adolescents with severe mental illness (5720 [68.0%] female; mean [SD] age, 14.8 [1.2] years), 5478 (65.1%) had continuous primary care, 2391 (28.4%) had discontinuous primary care, and 540 (6.4%) had no primary care during the transition period. Youths with no primary care during transition were more likely to be male (57.2%), have lower socioeconomic status (31.5%), and have no usual primary care practitioner at baseline (25.6%). Compared with continuous care, patients with discontinuous and no primary care had an increased rate of mental health-related hospitalization in young adulthood (adjusted relative rate, 1.20; 95% CI, 1.10-1.30; and adjusted relative rate, 1.30; 95% CI, 1.08-1.56, respectively). In the context of decreasing outpatient specialist mental health visit rates following transition to adult care, ensuring adequate access to primary care during this vulnerable period may improve mental health outcomes in young adulthood.
Highlights
Mental disorders are a critical health issue affecting 1 in 5 adolescents and young adults at any given time.[1,2] Most mental disorders begin in adolescence and early adulthood and are major contributors to the burden of disease in young people.[3,4,5,6] Most adolescents with severe mental disorders require a transition from pediatric to adult care practitioners because of the chronicity and functional impact of these disorders
Patients with discontinuous and no primary care had an increased rate of mental health– related hospitalization in young adulthood
When primary care is delivered by pediatricians, the mandatory transfer of care to a family physician at age 18 may be in addition to the transition of mental health care for adolescents with severe mental illnesses
Summary
Mental disorders are a critical health issue affecting 1 in 5 adolescents and young adults at any given time.[1,2] Most mental disorders begin in adolescence and early adulthood and are major contributors to the burden of disease in young people.[3,4,5,6] Most adolescents with severe mental disorders require a transition from pediatric to adult care practitioners because of the chronicity and functional impact of these disorders. In the United States, most youth transition to adult care between the ages of 18 and 21 years. In Ontario, Canada, government funding models mandate that the transfer of all pediatric care occur by age 18 years. This transition includes mental health care, as most child psychiatrists practice in pediatric hospitals. While most children and youth in Ontario have their primary care delivered by family physicians, a substantial number of pediatricians provide primary care to children, predominantly in larger urban centers.[7] Children with complex health care needs and those from families with higher income are more likely to have a pediatrician as their primary care practitioner.[7] When primary care is delivered by pediatricians, the mandatory transfer of care to a family physician at age 18 may be in addition to the transition of mental health care for adolescents with severe mental illnesses
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