(WITHDRAWN) Inequities in Contacts with Mental Health Professionals Among Refugees, Religious Minorities, Racialized Immigrants and Non-Immigrants with Current Psychological Symptoms

Purpose: This study aims to examine, within those with current psychological symptoms, whether racialized immigrants and refugees differ from Canadian-born whites in receiving mental health care regarding (1) the use of social work services that are publicly funded; and (2) the use of psychologist services that are out of the Canadian Medicare system.

Methods: Data were obtained from the Canadian Longitudinal Study on Aging (CLSA) baseline comprehensive cohort (2012-2015). The analysis was restricted to respondents who screened positive of mental health symptoms (N=6426) based on: 1) the Center for Epidemiologic Studies Depression Scale (CES-D-10); 2) the Kessler Psychological Distress Scale (K10), and/or; 3) the Primary Care PTSD Screen scale (PC-PTSD). Mental health service utilization was assessed with two Yes/No variables regarding any contact with 1) a psychologist or 2) a social worker about mental health in the previous 12 months. Multivariable binary logistic regression analyses were conducted for social worker visits or psychologist visits, respectively. Confounders were controlled including demographics (age, sex, marital status), socioeconomic status, social support, and multi-morbidities.

Results: Marked disparities by race, immigration status, refugee status, religious status, income and education were found in access to care from psychologists, but this inequities pattern were not observed in visits to social workers. After full adjustment, the odds of psychologist use were significantly lower among vulnerable populations, including refugees (OR=0.23, 95% CI: 0.05-0.96, versus non-refugee residents), racial minority immigrants (OR=0.55; 95% CI: 0.34-0.90, versus Canadian-born white), Muslim residents (OR=0.19, 95%CI: 0.04-0.90; versus Catholic residents), those financially disadvantaged with annual family income <$20,000 (OR=0.34, 95%CI: 0.22-0.51; versus ≥ $150,000), and participants who were in the lowest educational group (OR=0.54, 95%CI: 0.35-0.82; versus the highest educational group). On the contrary, these vulnerable populations with mental health needs were equally likely as the majority/advantage groups to have seen a social worker in the past year, given refugees (p=0.10), racial minority immigrants (p=0.16), Muslim residents (p=0.11), and participants in the lowest education group (p=0.14) did not statistically differ from their reference group. Those with the lowest household income (OR=1.59, 95%CI: 1.02-2.47) were even 1.6 times more likely to visit social workers than their peers with the highest income.

Conclusions: Safety-net providers-such as social workers-are the primary source of mental health care among immigrant and refugee communities. Inequities in mental health service use is more salient among clients of fee-demanding professionals than clients of safety-net providers, partly because social work programs often target and recruit higher proportions of minority populations. In the context of integrated inter-professional care practice, the findings underscore that vulnerable populations with severe mental illness may struggle to get adequate care from psychologists. To address their unmet mental health needs, social work clinicians as gatekeepers and system navigators should coordinate with other health allies to facilitate smooth transitions for these high-risk patients with disadvantaged backgrounds in receiving timely and approximately mental health treatment. At the policy level, the findings illustrate that the universal coverage for mental health services by social workers has been effective in tackling health care inequities.