This is the first study to investigate the determinants of timely access to Specialized Mental Health Services and maintenance of a link with Primary Care. Such work augments the current evidence-base and provides further evidence for understanding the factors that affect patient’s experiences in a complex mental health network with different forms of access and the aspects that foster continuity of care.
While being referred by Primary Care to the specialized service was negatively associated with timely access, this was positively associated with maintaining the link with Primary Care. Also, in relation to the diagnosis, it can be observed that patients diagnosed with psychosis and psychoactive substance misuse were more likely to access specialized services in a timely manner, however, they were less likely to maintain the link with Primary Care. These findings contribute to the global discussion about two important challenges for better mental health care, the low integration between Primary Care services and specialized services  and the barriers of access that individuals with mental health and/or substance use issues face in Primary Care .
Previous studies have also indicated that Primary Care contact was associated with longer delays accessing specialized mental health care [1,17]. However, at the same time, this type of contact was associated with better pathways to care, fewer contacts with emergency services, and greater adherence to specialized services . It appears, therefore, that the need for training Primary Care workers in the detection and management of mental health cases should be reinforced, as should be efforts to integrate the mental health care network.
Globally, several efforts have been made to establish greater integration between specialized services and Primary Care. In countries such as the United Kingdom, Spain and Canada, initiatives such as shared or collaborative care aims to link professionals and to develop strategies to collect and share information on the progress of patients .
It should be considered that in addition to enhancing the identification and management of mental health cases, the strengthening of this strategies could help in solving another major problem of the mental health care networks; namely, the low return of users to Primary Care levels. Previous studies have suggested that continuity of care is a critical issue when referring patients from specialized care back to Primary Care, as few people appear to reach Primary Care centers after referral [4,19].
In a study conducted in the United States with patients of a community mental health center , similar to our results, 41% of patients did not attend Primary Care in the six months prior to the survey. In the same study, 63% of patients were unable to identify a Primary Care provider by name and 14% reported using the emergency department for routine care.
Besides problems related to the continuity of mental health treatment, low contact with Primary Care appears to be a main contributor to the mortality gap experienced by people living with mental disorders worldwide . It is estimated that this population experiences mortality rates two to three times higher than the general population, with life expectancy reduced by 10-30 years . Among the factors contributing to these outcomes, there is a high prevalence in the population of hypertension, diabetes, heart disease and other conditions that could be treated by Primary Care, if identified in a timely manner [21,22].
Our results still raise an important discussion about the stigma related to psychosis and substance use. Both the greater absorption of these patients by specialized services and the lower likelihood that they will access Primary Care after being admitted to specialized services may be related to stigma. A study conducted in the United States  comparing professionals at both Primary Care and secondary healthcare centres found that physicians and nurses at Primary Care had more negative attitudes toward people with psychosis than their colleagues at secondary healthcare centres.
In relation to substance use, in addition to stigma, other social issues must be observed. Studies in Latin America [24,25] have shown that although some patients occasionally access the Primary Care to obtain clinical health care, the substance use is not brought up. The professionals in turn avoid talking about the subject because they do not wish to be mistaken as informants for the police or drug dealers .
In relation to the action of Primary Care, our results emphasize the importance of non-medical professionals in promoting the continuity of care. Among these professionals are the CHA, whose visits to users were associated with maintaining a link with Primary Care. Through home visits, these professionals are responsible for collecting information regarding the population's health needs, identifying users with health problems, and referring them to the health unit . Despite the importance of their role, however, they are often overlooked in the discussion of mental health cases management. This lack of recognition relative to other professions may stem from educational bias, as many CHA are individuals with a high school education .
Finally, we highlight that our results suggest that patients’ first steps in seeking help may influence other aspects of their trajectory within the health system. With the exception of those who attended their first mental health consultation after waiting more than a year, patients who waited more than 7 days to be treated were less likely to access specialized services in a timely manner (as compared to those who waited up to 7 days for treatment). These results are consistent with a review regarding the pathways to mental health care among young people , where the service responses to help-seeking were important determinants of patients’ pathways.
Some limitations should be considered in the interpretation of the present results. This is a cross-sectional study; therefore, reverse causality cannot be ruled out. Also, many variables were measured retrospectively, and thus are subject to recall error and bias. Additionally, it should be highlighted that this study recruited users who had access to and remained linked to specialized outpatient mental health services. Those who had previously discontinued care or did not have access to these services were therefore not included in our sample. Thus, in the city from which we drew our sample, the present results may not be representative of the full population with mental health disorders and their experiences in the mental health network.