Continuous primary care crucial in improving outcomes in adolescents with mental illness
Continuous primary care follow-up during the transition from adolescence to young adulthood could reduce the risk of mental illness-related hospitalizations post-transition in individuals with severe mental illness, according to a Canadian study.
“For adolescents with severe mental illness, timely and continuous access to primary care during their transition to adult care is associated with decreased mental health-related hospitalizations and emergency department (ED) visits,” said senior author Dr Astrid Guttmann, Chief Science Officer at the Institute for Clinical Evaluative Sciences (ICES) and paediatrician at The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.
“Our study suggests that primary care involvement in transitional care may be important for moderating or improving long-term health outcomes for youth with mental illness,” said Guttman and co-authors.
The study used ICES data of 8,409 adolescents aged 12–16 years (mean age 14.8 years, 68 percent female) from Ontario with childhood-onset severe mental illness, determined in this study as >72-hour hospitalization for schizophrenia and related psychotic disorders*, mood disorder, or eating disorder between April 2002 and 2014. About 87 percent of patients had a family physician as their primary care provider (rather than a paediatrician).
During the transition to adult care (age 17–18 years), 65.1 percent of patients consulted the same primary care physician as they did during adolescence (continuous primary care), 28.4 percent visited a different primary care physician (discontinuous primary care), and 6.4 percent received no primary care.
Male patients were more likely to have no primary care during the transition period (57.2 percent), as were patients with a lower socioeconomic status (31.5 percent), those in living in rural areas (population <10,000; 21.0 percent), and those without a primary care physician during adolescence (25.6 percent).
Over a mean 48.4-week follow-up**, patients with continuous, discontinuous, and no primary care had a mean 0.51, 0.65, and 0.44 mental health-related hospitalizations.
Following the transition period (age 19–26 years), there was a 20 and 30 percent increased risk of mental health-related hospitalizations in patients with discontinuous primary care during the transition period (adjusted relative rate [adjRR], 1.20, 95 percent confidence interval [CI], 1.10–1.30) and patients with no primary care [adjRR, 1.30, 95 percent CI, 1.08–1.56), respectively, compared with those with continuous primary care during transition. [JAMA Network Open 2019;2:e198415]
Patients with schizophrenia only (adjRR, 1.64, 95 percent CI, 1.45–1.84) had a higher likelihood of mental health-related hospitalizations, as did those with both schizophrenia and mood disorder (adjRR, 1.39, 95 percent CI, 1.22–1.58) compared with patients with mood disorder only. Conversely, patients with eating disorder only had a lower risk of mental health-related hospitalizations (adjRR, 0.77, 95 percent CI, 0.64–0.92).
Individuals with discontinuous primary care during transition also had an elevated risk of mental health-related ED visits following transition (adjRR, 1.16, 95 percent CI, 1.08–1.26) compared with those who had continuous care.
Of the 69 deaths that occurred post-transition, 41 had cause of death data available, with 54 percent attributed to suicide, self-inflicted injury, accidental poisoning, or transport accidents.
“Many adolescents with severe mental illness age out of paediatric care at [age] 18 [years] without a clear transfer of care to adult services. We sought to understand the extent to which family doctors provide stability across this vulnerable transition period,” said study lead author Dr Alene Toulany from ICES and SickKids.
The elevated rates of hospitalizations post-transition in patients with schizophrenia point to a crucial “gap in care” in this group, said the authors. They also noted that the reduced hospitalizations post-transition for those with eating disorder does not reflect resolution of the condition.
“For youth with eating disorder, ambivalence about treatment and recovery is a core feature of their illness, even in the face of significant medical complications, and resistance to recovery is common. Therefore, less follow-up care may be a means of maintaining their eating disorder,” they suggested.
The results may be limited by the exclusion of primary care in community health centres, and other healthcare providers such as social workers and psychologists, they added.