Child and Youth Mental Health Outcomes Report 2017 Table of Contents

Northwestern Health Unit Child and Youth Mental Health Outcomes Report 2017 Table of Contents

Acknowledgements ...... 2 Executive summary ...... 3 Introduction ...... 4 NWHU catchment area map ...... 5 Mortality ...... 6 Suicide ...... 6 Hospitalization...... 7 Intentional self-harm ...... 7 Mental and behavioural disorders ...... 9 Substance misuse ...... 12 Alcohol misuse ...... 14 Discussion and limitations ...... 15 References ...... 17 Appendix 1: Data sources and analysis methods ...... 18 Appendix 2: ICD-10 and DSM-IV codes ...... 20 Appendix 3: Definitions ...... 21 Appendix 4: Local Health Hubs ...... 23

List of figures

Figure 1: Age-specific mortality from suicide, NWHU and Ontario, rates per 100,000 per year, 2002-2011 combined ...... 6 Figure 2: Hospitalization from intentional self-harm in the 10-24 age group, rates per 100,000, 2008-2015 ...... 7 Figure 3: Hospitalization from intentional self-harm by age and sex, NWHU, rates per 100,000 per year, 2011-2015 combined ...... 8 Figure 4: Hospitalization from intentional self-harm by age and sex, NWHU and Ontario, rates per 100,000 per year, 2011-2015 combined ...... 8 Figure 5: Hospitalization from intentional self-harm in the 10-24 age group by Local Health Hub area, rates per 10,000 per year, 2008-2015 combined ...... 9 Figure 6: Hospitalization from mental and behavioural disorders in the 10-24 age group, rates per 10,000, 2008-2015 ...... 10 Figure 7: Hospitalization from mental and behavioural disorders by age and sex, NWHU and Ontario, rates per 10,000 per year, 2011-2015 combined ...... 11 Figure 8: Hospitalization from mental and behavioural disorders the 10-24 age group by Local Health Hub area, rates per 10,000 per year, 2008-2015 combined ...... 11 Figure 9: Causes of hospitalization from mental and behavioural disorders in the 10-24 age group, NWHU, 2015 ...... 12 Figure 10: Hospitalization from substance misuse by age group, NWHU and Ontario, rates per 100,000 per year, 2011-2015 combined ...... 13 Figure 11: Causes of hospitalization from substance misuse in the 10-24 age group, NWHU, 2011-2015 combined ...... 14 Figure 12: Hospitalization from alcohol misuse by age group, NWHU and Ontario, rates per 100,000 per year, 2011-2015 combined ...... 15

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 1 Acknowledgements

Thank you to Firefly for input into the development of this report. Without your passion, expertise and contributions the following report would not have been possible

Authors

Dorian Lunny, Epidemiologist

Samantha Jibb, Planning and Evaluation Specialist

Editors

Kit Young Hoon, Medical Officer of Health

Alex Berry, Manager, Foundations and Communications Services

For more information about this report, please contact:

Kit Young Hoon, Medical Officer of Health 210 First Street North, Kenora, ON P9A 2K4 807-274-9827 ex: 3266 [email protected]

Samantha Jibb, Planning and Evaluation Specialist 396 Scott Street, Fort Frances, ON P9A 1G9 807-274-9827 ex: 3647 [email protected]

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 2 Executive summary

This report outlines key population health indicators relating to mental health outcomes in the population aged 10-24 in Northwestern Ontario. The statistics in the report focus on the geographical area of the Northwestern Health Unit (NWHU) catchment area and focus on intentional self-harm and suicide, hospitalization from mental and behavioural disorders, as well as alcohol and substance misuse.

Some key findings of the report include:

 Between 2002 and 2011 the mortality rate from suicide in the 15-24 age group in the NWHU area was 59.1 per 100,000 per year. o This is eight times as high as the provincial rate in this age group of 7.4 per 100,000 per year. o It is also statistically higher than the rates in all other age groups in the NWHU area.  In 2015 there were 75 hospitalizations from intentional self-harm in the NWHU area in the 10-24 population. o This equals an incidence rate of 447.2 per 100,000, which is nearly four times as high as the provincial rate of 118.1 per 100,000. o 63 of these hospitalizations (84%) were in females, who have much higher rates than males in this younger age group.  The population aged 10-24 in the NWHU area has higher rates of hospitalization from mental and behavioural disorders compared to the province. o In 2015 the rate in the NWHU area was 153.8 per 10,000, which was statistically higher than the provincial rate of 94.9 per 10,000. o The rate in the NWHU area increased by 40% between 2008 and 2015.  Hospitalization rates from substance misuse in the 10-24 population are also higher in the NWHU area compared to the province. o In 2015 there were 29 hospitalizations from mental and behavioural disorders caused by substance misuse in this population in the NWHU area. At a rate of 172.9 per 100,000, this was over twice as high as the provincial rate of 76.2 per 100,000.  Alcohol is the leading cause of substance-misuse hospitalization among the 10-24 population. o The hospitalization rate from alcohol misuse in the NWHU area between 2011 and 2015 was 70.6 per 100,000 per year, over five times as high as the provincial rate of 13.1 per 100,000 per year.

These indicators provide evidence that child and youth mental health outcomes are particularly adverse in Northwestern Ontario, and help to focus in on key areas and demographics that can be targeted for improvement.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 3 Introduction

It is estimated that approximately 20% of children and youth in Ontario experience a mental health challenge (MCYS, 2016). The Centre for Addictions and Mental Health (CAMH) reported that youth aged 15-24 were more likely than any other age group to experience a mental illness and/or substance abuse disorder (2016). Since 70% of mental health challenges begin in childhood or adolescence (MCYS, 2016), the need to understand and address child and youth mental health is becoming a top priority in Ontario, and around the world. Mental illness can greatly affect child and adolescent development, success in school and ability to live a fulfilling and productive live (WHO, 2016), highlighting the need to support this age group.

The need to support and address child and youth mental health is evident given that suicide is the second leading cause of death among youth aged 10-24 in Canada (PHAC, 2016). The ‘Youth Suicide Prevention Plan’ reports that in the last year in Ontario, 10% of students had suicidal thoughts, 3% reported a suicide attempt and that suicide is 5-7 times higher for First Nations and Inuit than non-aboriginal youth (2016). Additionally, in 2012 suicide accounted for 17% of deaths among youth aged 10-14, 28% among those aged15-19 years and 25% of the 20-24 year old population (CAMH, 2016). The Canadian Institute for Health Information (CIHI) reported that 5% of emergency department and 18% of inpatient hospitalizations for children and youth aged 5-25 in Canada were for a mental disorder in 2013/2014 (2015). Furthermore, emergency department and inpatient hospitalizations for mental disorders have increased by 45% for children and 37% for youth between 2006/07 and 2013/14 (CIHI, 2015).

The Northwestern Health Unit (NWHU) catchment area includes the Rainy River District and the western part of the Kenora District. This area includes 19 municipalities, 40 First Nations communities and two unincorporated territories (Kenora unorganized and Rainy River unorganized). The population of about 82,000 people is widely scattered across 171,288 square kilometers, or approximately one-fifth of the province. This report will focus on the outcomes of mental illness in children and youth aged 10-24 in the NWHU catchment area, and when the term “Northwestern Ontario” is used, it is referring to this catchment area. By examining the rates of mortality and hospitalization that result from mental illness among children and youth, programs in Northwestern Ontario can gain a better understanding of the supports and resources needed to support this age group.

Population health indicators in this report are often reported by Local Health Hub (LHH) area where possible. These Local Health Hubs act as “mini catchment areas” within the larger NWHU catchment area, and provide a way to geographically group the communities in the area. More information about the Local Health Hubs within the NWHU catchment area can be found in Appendix 4 of this report.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 4 NWHU catchment area map

Note: Only municipalities with NWHU branch offices are included in the map

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 5 Mortality

Suicide

In the 10 years between 2002 and 2011, there were 70 suicides in the NWHU catchment area in the population aged 15-24; equaling an incidence rate of 59.1 per 100,000 per year. This is eight times as high as the provincial rate in this age group during the same time, which was 7.4 per 100,000 per year.

This incidence rate is also statistically higher than the rates in all other age groups in the NWHU catchment area. Figure 1 displays rates across the age spectrum for the NWHU area and for Ontario as a comparison. This figure demonstrates the significant gap between rates in young people and the rest of the population.

During this time period, males in the 15-24 age group had a higher mortality rate than females (71.0 per 100,000 per year vs. 46.7 per 100,000 per year), but the difference was not statistically significant.

Furthermore, it is important to note that although the data represents the population aged 15-24 years old, there are also incidence of suicide among children under the age of 15 years; however, the number of cases in that population are very small and therefore cannot be analyzed meaningfully.

Figure 1: Age-specific mortality from suicide, NWHU and Ontario, rates per 100,000 per year, 2002-2011 combined 80

40 NWHU 30 Ontario 20

Deaths Deaths per 100,000 per year 10

0 15-24 25-34 35-44 45-54 55-64 65+ Age group

Source: Ontario Mortality Data 2002-2011. Ontario Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: September 26, 2016.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 6 Of the 70 suicides that occurred in the 15-24 age group during this time, the majority (80.0%) were committed by hanging, suffocation or strangulation. The second most common method with an additional 11.4% of cases was suicide by firearm discharge.

Hospitalization

Intentional self-harm

Intentional self-harm refers to the intentional, direct injuring of one’s own body tissue. This can be done either with or without suicidal intentions.

In 2015 there were 75 hospitalizations due to intentional self-harm in the NWHU catchment area in the population aged 10-24 years old. This equals an incidence rate of 447.2 per 100,000, which is just under four times as high as the provincial rate of 118.1 per 100,000, a statistically significant difference.

Incidence rates in the NWHU area have been steadily increasing since 2011; the incidence rate in 2015 was twice as high as the rate was in 2011. Provincial rates have also been increasing over this time period.

Figure 2: Hospitalization from intentional self-harm in the 10-24 age group, rates per 100,000, 2008-2015 500 450 400 350 300 250 200 150 100 Hospitalizations per 100,000 50 0 2008 2009 2010 2011 2012 2013 2014 2015 NWHU 291.2 271.9 253.3 233.1 275.3 346.5 401.7 447.2 Ontario 74.0 69.6 78.2 76.2 97.5 106.7 112.4 118.1

Source: Inpatient Discharges 2008-2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: September 1, 2016.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 7 Furthermore, hospitalization rates are highest amongst females in younger age groups. Looking at combined incidence rates between 2011 and 2015, the highest rates by far were in females aged 10-14 and 15-19, with rates of 510.4 per 100,000 per year and 679.5 per 100,000 per year respectively. Both of these rates are statistically higher than rates in all the other age- sex demographics.

Figure 3: Hospitalization from intentional self-harm by age and sex, NWHU, rates per 100,000 per year, 2011-2015 combined 900 800 700 600 500 400 Males 300 Females 200 100 0 Hospitalizations per 100,000 per year 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+ Age group

Source: Inpatient Discharges 2008-2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: September 1, 2016.

Figure 4: Hospitalization from intentional self-harm by age and sex, NWHU and Ontario, rates per 100,000 per year, 2011-2015 combined 900 800 700 600 500 NWHU Males 400 Ontario Males 300 NWHU Females 200 Ontario Females 100 0 Hospitalizations per 100,000 per year 10-14 15-19 20-24 Age group

Source: Inpatient Discharges 2008-2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: September 1, 2016.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 8 Between 2008 and 2015, the Sioux Lookout Local Health Hub had the highest hospitalization rates from self-harm in the NWHU catchment area in the population aged 10-24 (for information on Local Health Hubs, see Appendix 4). During this time, the hospitalization rate for this population was 48.9 per 10,000 per year in the Sioux Lookout area, statistically higher than the catchment area rate of 31.4 per 10,000 per year. Sioux Lookout’s rate was also statistically higher than the rates in all of the other local health hubs

Figure 5: Hospitalization from intentional self-harm in the 10-24 age group by Local Health Hub area, rates per 10,000 per year, 2008-2015 combined 60

Hospitalizations per 10,000 per year 0 Ontario Entire NWHU Sioux Lookout Kenora Red Lake Dryden Fort Frances, catchment area Rainy River, Emo, Atikokan

Source: Inpatient Discharges 2008-2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: September 1, 2016.

Mental and behavioural disorders

Mental and behavioural disorders refers to a chapter in the International Statistical Classification of Disease 10th Revision (ICD-10). This chapter covers a wide variety of conditions such as mood disorders, disorders due to substance use, neurotic disorders, mental retardation, amongst others. A description of the ICD-10 codes used in this analysis can be found in Appendix 2.

People who are admitted as inpatients into hospital are captured in the aforementioned ICD-10 codes through the Discharge Abstract Database (DAD). Additionally, some patients are admitted into designated adult mental health beds in Ontario. This data is captured in the Ontario Mental Health Reporting System (OMHRS), which uses the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). Information on these diagnostic codes can be found in Appendix 2.

Data in this section refers to hospitalizations from both the DAD as well as OMHRS.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 9 In 2015 there were 258 hospitalizations in the NWHU area for those aged 10-24 years old, due to mental and behavioural disorders. This equals an incidence rate of 153.8 hospitalizations per 10,000, which is statistically higher than the provincial rate of 94.9 per 10,000 in 2015. Incidence rates have consistently been higher in the NWHU area over the past eight years. Rates have also been increasing during this time in the NWHU area as well as provincially. In 2015 the rate in the NWHU area was 40% higher than the rate in 2008, with the increase being statistically significant.

Figure 6: Hospitalization from mental and behavioural disorders in the 10-24 age group, rates per 10,000, 2008-2015 180 160 140 120 100 80 60 40 Hospitalizations per 10,000 20 0 2008 2009 2010 2011 2012 2013 2014 2015 NWHU 109.8 111.6 107.1 100.2 125.9 132.1 145.3 153.8 Ontario 58.5 59.3 63.4 67.3 81.3 89.3 93.1 94.9

Sources: Inpatient Discharges 2008-2015, Ministry of Health and Long-Term Care, IntelliHEALTH Ontario, Date Extracted: June 7, 2016; OMHRS 2008-2015, Ministry of Health and Long-Term Care, IntelliHEALTH Ontario, Date Extracted: June 7, 2016

Looking at hospitalization incidence broken down by age and sex, there are some significant differences. In the 10-14 age group, the 5-year combined incidence rate in females is four times as high as the rate in males. Conversely, in the 20-24 age group the male incidence rate is statistically higher than the female rate. The highest rates overall are in the 15-19 age group.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 10 Figure 7: Hospitalization from mental and behavioural disorders by age and sex, NWHU and Ontario, rates per 10,000 per year, 2011-2015 combined 250

200

150 NWHU Males Ontario Males 100 NWHU Females 50 Ontario Females

Hospitalizations per 10,000 per year 10-14 15-19 20-24 Age group

Between 2008 and 2015 the Sioux Lookout Local Health Hub had the highest rates of hospitalization from mental and behavioural disorders. During this time, the rate there was 156.2 per 10,000 per year, which is statistically higher than the NWHU catchment area rate of 123.0 per 10,000 per year. The Sioux Lookout area rate was also statistically higher than all of the other Local Health Hub rates except for Red Lake.

Figure 8: Hospitalization from mental and behavioural disorders the 10-24 age group by Local Health Hub area, rates per 10,000 per year, 2008-2015 combined 180 160 140 120 100 80 60 40 20 0

Hospitalizations per 10,000 per year Ontario Entire NWHU Sioux Lookout Red Lake Dryden Kenora Fort Frances, catchment area Rainy River, Emo, Atikokan

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 11 Out of the 258 hospitalizations that occurred in the 10-24 age group in the NWHU area in 2015, the most common reason was for schizophrenia or other psychotic disorders. These disorders accounted for 55 hospitalizations, which was about a fifth of all the cases. Mood disorders accounted for an additional 54 hospitalizations, and other common reasons were substance misuse, adjustment disorders, and neurotic and stress-related disorders. Definitions for the various mood and behavioral disorders can be found in appendix 3.

Figure 9: Causes of hospitalization from mental and behavioural disorders in the 10-24 age group, NWHU, 2015 60 50 40 30 20

# hospitalizations# 10 0 Schizophrenia and Mood disorders Substance misuse Adjustment Neurotic and Other disorders other psychotic disorders stress-related disorders disorders Reason for hospitalization

Substance misuse

Substance misuse refers to a block of ICD-10 codes that cover mental and behavioural disorders due to psychoactive substance use, as well as substance-related codes in the DSM- IV. This includes hospitalization for causes such as acute intoxication, substance abuse, harmful use, dependence, withdrawal, amongst other substance-related conditions. A full list of ICD-10 and DSM-IV codes used in the analysis can be found in Appendix 2.

In 2015, there were 29 hospitalizations from substance misuse in the 10-24 age group in the NWHU catchment area. This equals an incidence rate of 172.9 per 100,000, which is 2.3 times as high as the provincial rate of 76.2, a statistically significant difference. Rates in the NWHU area in this age group have been consistently higher than the province in recent years.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 12 Looking at 5-year combined hospitalization rates from 2011 to 2015 by age group, the NWHU area has considerably higher rates than Ontario across all age groups in the 10-24 population. The highest rates are in the 20-24 age group, with a rate of 285.0 per 100,000 per year in the NWHU area.

Figure 10: Hospitalization from substance misuse by age group, NWHU and Ontario, rates per 100,000 per year, 2011-2015 combined 400

350

300

250

200 NWHU 150 Ontario 100

50 Hospitalizations per 100,000 per year 0 10-14 15-19 20-24 Age group

Alcohol-related issues are the most frequent cause of substance misuse hospitalization amongst the 10-24 age group in the NWHU area. Between 2011 and 2015, out of 141 hospitalizations from substance misuse, 60 were related to alcohol use (42.5%). Other common causes were related to cannabinoid use, opioid use, and substance-induced psychotic disorders.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 13 Figure 11: Causes of hospitalization from substance misuse in the 10-24 age group, NWHU, 2011-2015 combined 70

# hospitalizations# 20

0 Alcohol-related Other Cannabinoid-related Substance-induced Opioid-related psychotic disorder Cause

Alcohol misuse

Alcohol misuse refers to a subcategory of substance misuse, discussed in the previous section. With alcohol being the most frequent substance involved in substance misuse hospitalizations in the NWHU area, it is important to examine its trends as its own category. A full list of the ICD-10 and DSM-IV codes used in analyzing alcohol misuse hospitalizations can be found in Appendix 2.

Over the past five years between 2011 and 2015 there were 60 hospitalizations from alcohol misuse in the 10-24 age group within the NWHU catchment area. This is an incidence rate of 70.6 per 100,000 per year, which is over five times as high as the provincial rate of 13.1 per 100,000 per year, with the difference being statistically significant.

Figure 14 below displays hospitalization rates by age group for the NWHU area and Ontario. The 20-24 year-olds have the highest rates; in the NWHU area their rate is 140.7 per 100,000 per year, which is six times as high as the province-wide rate in this age group. Rates were also statistically higher in the NWHU area in all the other age groups.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 14 Figure 12: Hospitalization from alcohol misuse by age group, NWHU and Ontario, rates per 100,000 per year, 2011-2015 combined 200 180 160 140 120 100 NWHU 80 Ontario 60 40 20 Hospitalizations per 100,000 per year 0 10-14 15-19 20-24 Age group

Discussion and limitations

The statistics and trends outlined in this report indicate that mortality and morbidity from mental health-related conditions amongst youth is a concern in Northwestern Ontario. Locally, we consistently have higher rates of suicide and self-harm, mental and behavioural conditions and substance misuse.

In recent years mortality rates from self-harm in Northwestern Ontario have been higher than provincial rates when examining the entire population. The statistics in this report indicate that this is a particular problem amongst the younger population. In the population aged 15-24 in the NWHU catchment area, mortality rates from intentional self-harm are eight times as high as the provincial rate. In older populations these rates become closer to provincial rates, highlighting the concern within the younger demographic.

Similarly, rates of hospitalization from self-harm are particularly high amongst the younger population in the NWHU catchment area. Also, females have statistically higher rates than males when it comes to hospitalization.

Looking at rates of hospitalization from other mental and behavioural disorders, rates in the NWHU catchment area are higher than the province in both males and females in the youth

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 15 population. One of the most common areas of mental and behavioural disorder in the area is substance misuse, particularly alcohol.

One limitation of the statistics in this report is that they are only focused on the outcomes of mental health problems (i.e. deaths, hospitalizations). This is important information to examine however, it leaves out the upstream causes that lead to these outcomes. Future reports will attempt to delve deeper into these root causes, but it is important to note that there is far more data available that look at outcomes. The comparative lack of thorough and frequently updated data on root causes of mental health issues is a concern.

Another limitation is the small sample sizes often encountered when analyzing with local data. Due to the relatively small population in Northwestern Ontario, some of the numbers being analyzed in this report were quite low, making analysis challenging. Because of this, for many of the indicators in the report multiple years of data had to be combined in order to provide stable estimates. While this solution produces reliable statistics, the downside is that you are unable to examine temporal trends as effectively.

All of this considered, these statistics provide locally relevant information on the mental health of the youth population in Northwestern Ontario. Mental health is clearly an area of concern for youth in the area, evidenced by our high rates of mortality and morbidity from self-harm, substance misuse, and other mental and behavioural disorders. The next step is to examine the factors that lead to these outcomes and the development or enhancement of solutions.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 16 References

The Provincial Centre of Excellence for Child and Youth Mental Health at Children’s Hospital of Eastern Ontario (CHEO), The National Infant, Child and Youth Mental Health Consortium Advisory and The Canadian Association of Pediatric Health Centres (2010). Access and Wait Times in Child and Youth Mental Health: A Background Paper. Retrieved on: 10 November, 2016. Retrieved from: http://www.excellenceforchildandyouth.ca/sites/default/files/policy_access_and_wait_times.pdf

Canadian Centre for Addiction and Mental Health (CAMH). Mental Illness and Addictions: Facts and Statistics. (n.d.). Retrieved on: 17 August, 2016. Retrieved from: http://www.camh.ca/en/hospital/about_camh/newsroom/for_reporters/Pages/addictionmentalhe althstatistics.aspx

Canadian Institute for Health Information (CIHI). Care for children and youth with mental disorders. Ottawa, ON: CIHI, 2015. Retrieved on: 11 November, 2016. Retrieved from: https://secure.cihi.ca/free_products/CIHI%20CYMH%20Final%20for%20pubs_EN_web.pdf

Ontario Ministry of Children and Youth Services (MCYS). Mental Health Services. (2016, July 15). Retrieved on: 10 November, 2016. Retrieved from: http://www.children.gov.on.ca/htdocs/English/specialneeds/mentalhealth/index.aspx

The Public Health Agency of Canada (PHAC) (2016). Leading causes of death, Canada, 2008, males and females combined, counts (age-specific death rate per 100,000). Retrieved on: 10 November, 2016. Retrieved from: http://www.phac-aspc.gc.ca/publicat/lcd-pcd97/table1- eng.php

World Health Organization (2016). Child and adolescent mental health. (n.d.). Retrieved on 10 November, 2016. Retrieved from: http://www.who.int/mental_health/maternal- child/child_adolescent/en/

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 17 Appendix 1: Data sources and analysis methods

All of the data in this report were extracted between June and September of 2017, and came from Vital Statistics Mortality Data, the Discharge Abstract Database (DAD) and the Ontario Mental Health Reporting System (OMHRS). These data sources were all accessed through IntelliHEALTH Ontario.

IntelliHEALTH Ontario

IntelliHEALTH Ontario is a provincial portal maintained by the Ministry of Health and Long-Term Care, which pulls together administrative data from several databases. The portal can be accessed by authorized users who use the data for analysis and planning of healthcare delivery in Ontario.

Vital Statistics Mortality Data

This database includes data on all deaths that occur in Ontario, originally distributed by the Ontario Office of Registrar General (ORG), and accessed through IntelliHEALTH Ontario. The ORG provides death registration data to Statistics Canada for national reporting, and with ORG’s permission, Statistics Canada provides the Ministry of Health and Long-Term Care (MOHLTC) with an edited and standardized dataset for Ontario deaths, which is uploaded to IntelliHEALTH.

Discharge Abstract Database (DAD)

The DAD captures administrative, clinical and demographic information on hospital discharges across Canada. The MOHLTC receives this data from the Canadian Institute for Health Information (CIHI) and uploads it to IntelliHEALTH.

Ontario Mental Health Reporting System (OMHRS)

OMHRS collects, analyzes and reports on information submitted to CIHI about individuals admitted to designated adult mental health beds in Ontario. The MOHLTC receives this data from CIHI and uploads it to IntelliHEALTH.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 18 Data Analysis

Mortality and incidence rates were calculated using the following formula:

# 표푓 푐푎푠푒푠 * 100,000 푃푒푟푠표푛−푦푒푎푟푠

Confidence intervals for age-specific incidence rates were calculated using the Mid-P Exact method. Tests for statistical differences between incidence rates were carried out by calculating the odds ratio using the Mid-P Exact method. Results were considered statistically significant if the 95% confidence interval around the calculated odds ratio did not contain 1.

Records without a valid age were excluded from age-specific incidence rate calculations, and records without a valid sex were excluded from sex-specific incidence rate calculations. Such records were rare, however, making up <1% of all records in Ontario.

All data analysis for mortality and hospitalization rates was based on the home residence of the individual, not where they were hospitalized or died. Hospitalization and mortality data are captured for all Ontario residents who died or were hospitalized in Ontario. Out of province deaths and hospitalizations for Ontario residents are not captured in the data.

As an example, if a Kenora resident was hospitalized somewhere else in Ontario (i.e. Thunder Bay), for this analysis they are still coded under “Kenora.” However, if this resident was hospitalized out of province their record would not show up in the database.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 19 Appendix 2: ICD-10 and DSM-IV codes

International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)

The ICD-10 is a medical classification list developed by the World Health Organization (WHO) which contains standardized codes for diseases, signs and symptoms, complaints, social circumstances and external causes of injury or disease. A listing of the codes can be found here: http://apps.who.int/classifications/icd10/browse/2010/en.

Diagnostic and Statistical Manual of Mental Disorders Version IV (DSM-IV)

The DSM is a classification system that offers a common language and a standard criteria for the classification of mental disorders, and is published by the American Psychiatric Association (APA). A listing of the codes can be found here: http://behavenet.com/dsm-iv-tr-numerical- listing-codes-and-diagnoses.

All of the indicators in this report were based on classifications from ICD-10 or DSM-IV, or a combination of both. For people hospitalized for mental health-related reasons, they can either be admitted as an inpatient into an acute care hospital, in which case their record is captured in the DAD and ICD-10 is used as classification. Or, if a patient is admitted into an adult mental health bed their record is captured in OMHRS, which uses DSM-IV. For mental health hospitalizations, both of these scenarios are combined to obtain total numbers.

The following codes were used in classifying the data used in this report:

Indicator Database(s) ICD-10 codes DSM-IV codes Mortality from suicide Vital Statistics X60-X84 n/a Mortality Data Hospitalization from DAD X60-X84 n/a intentional-self harm Hospitalization from DAD, OMHRS F00-F99 290.40-V71.09 (all mental and codes included) behavioural disorders Hospitalization from DAD, OMHRS F10-F19 291.0-292.9, 303.00- substance misuse 305.90 Hospitalization from DAD, OMHRS F10-F19 291.0-291.9, 303.00- alcohol misuse 303.90, 305.00

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 20 Appendix 3: Definitions

Adjustment disorders: Defined as states of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event. The stressor may have affected the integrity of an individual's social network (bereavement, separation experiences) or the wider system of social supports and values (migration, refugee status), or represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement).

Alcohol misuse: A subcategory of substance misuse, which includes a wide variety of disorders attributable to the use of alcohol.

Hospitalization: Hospitalization refers to when a patient has been admitted as an inpatient into a hospital, and is taking a bed for further tests and/or examinations.

Incidence: incidence refers to a measure of the probability of occurrence of an event (i.e. hospitalization) in a population within a specified period of time. It is usually expressed as a rate with a denominator (i.e. 20 hospitalizations per 100,000 people per year).

Intentional self-harm: Intentional self-harm refers to the intentional, direct injuring of one’s own body tissue. This can be done either with or without suicidal intentions

Mental and behavioural disorders: refers to a chapter in the International Statistical Classification of Disease 10th Revision (ICD-10). This chapter covers a wide variety of conditions such as mood disorders, disorders due to substance use, neurotic disorders, mental retardation, amongst others. Similar disorders are also classified in the Diagnostic and Statistical Manual of Mental Disorders Version IV (DSM-IV)

Mood disorders: Mood disorders are considered a change in affect or mood to depression (with or without associated anxiety) or to elation. The mood change is usually accompanied by a change in the overall level of activity; most of the other symptoms are either secondary to, or easily understood in the context of, the change in mood and activity. Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations.

Neurotic and stress-related disorders: Refers to a number of different disorders including a variety of different phobias, anxiety disorders, disorders that result from periods of stress, and other neurotic disorders.

Schizophrenia: The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. The course of schizophrenic disorders can be either continuous, or episodic with progressive or stable deficit, or there can be one or more episodes with complete or incomplete remission.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 21 Substance misuse: This category includes a wide variety of disorders that differ in severity and clinical form but that are all attributable to the use of one or more psychoactive substances, which may or may not have been medically prescribed. It is the abuse of non-dependence- producing substances like drugs or alcohol.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 22 Appendix 4: Local Health Hubs

A Local Health Hub (LHH) refers to a health service delivery area where most or all sectors of the health system are linked in order to improve patient access

The Northwest Local Health Integration Network (NW LHIN) is comprised of five Integrated District Networks (IDN’s), and within these IDN’s there are a total of 14 LHH’s. Eight of these LHH’s fall within the NWHU catchment area, while the others fall within the Thunder Bay District Health Unit (TBDHU) catchment area .The Sioux Lookout LHH falls partly with the NWHU catchment area, and partly within the TBDHU catchment area. For this analysis, only communities that fall within the NWHU catchment area were included.

Atikokan LHH:

CSD/Community Type of CSD Population (2015) Atikokan Township 2,747 Seine River 23A First Nation Reserve 272 Seine River 23B First Nation Reserve 0 Neguaguon Lake 25D First Nation Reserve 195 LHH Total 3,214 Data source: Population Estimates 2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: January 10, 2017.

Dryden LHH:

CSD/Community Type of CSD Population (2015) Dryden City 7,941 Wabigoon Lake 27 First Nation Reserve 194 Machin First Nation Reserve 964 Eagle Lake 27 First Nation Reserve 241 Ignace Township 1,263 LHH Total 10,603 Data source: Population Estimates 2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: January 10, 2017.

Emo LHH:

Includes Emo, Sabaskong Bay (Part) 35C, Chapple, and Manitou Rapids 11

CSD/Community Type of CSD Population (2015) Emo Township 1,218 Sabaskong Bay (Part) 35C First Nation Reserve 0 Chapple Township 731 Manitou Rapids 11 First Nation Reserve 309 LHH Total 2,258 Data source: Population Estimates 2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: January 10, 2017.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 23

Fort Frances LHH:

CSD/Community Type of CSD Population (2015) Fort Frances Town 7,810 Alberton Township 846 La Vallee Township 963 Couchiching 16A First Nation Reserve 769 Rainy Lake 17A First Nation Reserve 212 Rainy Lake 17B First Nation Reserve 5 Rainy Lake 18C First Nation Reserve 95 Rainy Lake 26A First Nation Reserve 156 LHH Total 10,856 Data source: Population Estimates 2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: January 10, 2017.

Rainy River LHH:

CSD/Community Type of CSD Population (2015) Rainy River Township 834 Big Grassy River 35G First Nation Reserve 247 Dawson Township 549 Morley Township 467 Rainy River, Unorganized Unorganized 1,176 Lake of the Woods Township 291 Big Island Mainland 93 First Nation Reserve 0 Long Sault 12 First Nation Reserve 36 Saug-a-Gaw-Sing 1 First Nation Reserve 119 LHH Total 3,719 Data source: Population Estimates 2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: January 10, 2017.

Red Lake LHH:

CSD/Community Type of CSD Population (2015) Red Lake Municipality 4,859 Ear Falls Township 1,082 Wabauskang 21 First Nation Reserve 79 LHH Total 6,020 Data source: Population Estimates 2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: January 10, 2017.

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 24

Kenora LHH:

CSD/Community Type of CSD Population (2015) Kenora City 16,023 Sioux Narrows-Nestor Falls Township 759 Whitefish Bay 32A First Nation Reserve 691 Whitefish Bay 33A First Nation Reserve 81 Whitefish Bay 34A First Nation Reserve 132 Shoal Lake (Part) 39A First Nation Reserve 401 Shoal Lake (Part) 40 First Nation Reserve 104 Shoal Lake 34B2 First Nation Reserve 101 Rat Portage 38A First Nation Reserve 378 The Dalles 38C First Nation Reserve 200 Kenora 38B First Nation Reserve 407 Kenora, Unorganized Unorganized 7,384 Northwest Angle 33B First Nation Reserve 90 English River 21 First Nation Reserve 659 Wabaseemoong First Nation Reserve 851 Lake of the Woods 37 First Nation Reserve 48 Sabaskong Bay (Part) 35C First Nation Reserve 0 Sabaskong Bay 35D First Nation Reserve 402 LHH Total 28,711 Data source: Population Estimates 2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: January 10, 2017.

Sioux Lookout LHH:

CSD/Community Type of CSD Population (2015) Bearskin Lake First Nation Reserve 406 Cat Lake 63C First Nation Reserve 501 Deer Lake First Nation Reserve 777 Fort Hope 64* First Nation Reserve 1,095 Fort Severn 89* First Nation Reserve 348 Kasabonika Lake* First Nation Reserve 899 Kee-Way-Win First Nation Reserve 346 Kingfisher Lake 1* First Nation Reserve 415 Kitchenuhmaykoosib Aaki 84 First Nation Reserve 934 (Big Trout Lake)* Lac Seul 28 First Nation Reserve 906 Landsdowne House* First Nation Reserve 0 MacDowell Lake First Nation Reserve 0 Muskrat Dam Lake First Nation Reserve 266 Neskantaga First Nation Reserve 242 North Spirit Lake First Nation Reserve 266 Osnaburgh 63B First Nation Reserve 436

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 25 Pickle Lake Township ** 444 Pikangikum 14 First Nation Reserve 2,290 Poplar Hill First Nation Reserve 509 Sachigo Lake 1 First Nation Reserve 428 Sandy Lake 88 First Nation Reserve 1,880 Sioux Lookout Municipality 5,222 Slate Falls Settlement 197 Summer Beaver* Settlement 343 Wapakeka 2* First Nation Reserve 385 Wawakapewin (Long Dog First Nation Reserve 23 Lake)* Weagamow Lake First Nation Reserve 826 Webequie* First Nation Reserve 672 Wunnumin 1* First Nation Reserve 500 LHH Total 21,556 Data source: Population Estimates 2015. Ministry of Health and Long-Term Care. IntelliHEALTH Ontario. Date Extracted: January 10, 2017. *These communities fall within the Thunder Bay District Health Unit (TBDHU), and were excluded from the analyses in this report.

** Report corrected to identify Pickle Lake as a Township

More information about Local Health Hubs can be found at: http://www.northwestlhin.on.ca/goalsandachievements/Health%20Services%20Blueprint/ Bluepri ntTools/LocalHealthHubProfiles.aspx

Northwestern Health Unit Child and Youth Mental Health Outcomes Report, 2017 26