This study found that MH service use in all settings (i.e., community, emergency department, and hospital) was lower among immigrant youth than non-immigrant youth, consistent with existing literature [12, 33]. As reported in prior studies [7, 34], non-immigrant youth in lower-income neighbourhoods interacted more with MH services than those in higher-income neighbourhoods. However, the reverse income gradient observed for immigrant youth for community-based MH visits was unexpected and noteworthy.
Findings are in contrast to an Ontario study which found that adult immigrants in more materially deprived quintiles had more interactions with primary MH care than immigrants in less materially deprived quintiles [7]. One possible explanation for the variation in findings is that the Ontario study grouped long-term immigrants with Canadian-born and used material deprivation as the indicator, which included people receiving government transfer payment, unemployment, single-parent families, education level, and individuals living below the poverty line.
Given the relationship between poverty and mental illness [35], lower service use among immigrant youth in low-income neighbourhoods observed in our study cannot plausibly be explained by having lower needs, especially when significantly higher service use was found among non-immigrant youth from lower-income neighbourhoods. Other national research has found that immigrants had unmet MH needs [36] and that immigrants are less likely to have a MH consultation than their Canadian-born counterparts, even when reporting poor MH [37]. Our interpretation is that our results point to profound and entrenched barriers to accessing community-based services for immigrant youth, particularly those in lower-income settings.
One potential reason why immigrants in low-income neighbourhoods use fewer MH services is that recent immigrants are overrepresented in low-income neighbourhoods [38], and newcomers face several numerous documented barriers to receiving adequate health care [39]. Evidence shows that recent immigrants and people of lower-income in Canada are less likely to be attached to a family doctor [40] and, thereby, possibly less likely to access MH care in the community. Our findings also align with a US study that found that immigrant children whose parents have higher education were found to use more MH services [41], which could suggest that having higher education and income reduces barriers for immigrant youth accessing MH services.
Existing literature has found several factors shaping lower use of MH services among immigrants, including language barriers, distrust of health systems in destination countries, less knowledge about health services, different recognition of mental illness, and higher stigma in seeking MH services [42]. Prior studies found that a higher degree of cultural identification with the destination country [33] and number of years since immigrating [43] were associated with increased use of MH services, suggesting increased awareness of MH services, MH literacy, and reduced stigma with years spent in the destination country. However, a study of Chinese immigrants in British Columbia revealed that MH services continue to be underused by second-generation Chinese immigrants at moderate to high risk for depression [44], suggesting there are factors other than language proficiency and the number of years in Canada limiting access to MH services.
A Canadian study revealed that new immigrants have limited knowledge about the role of primary care providers and are unaware they can assist them in their MH care [45]. Immigrant youth and immigrant parents may rely on emergency departments as a first point of contact rather than a primary care physician who could assess for mental illnesses, refer them to community-based services, or manage common mental illnesses, like depression, anxiety, and attention-deficit/hyperactivity disorder.
Notably, proportions of involuntary hospitalization were higher among immigrant youth than non-immigrant youth. This is consistent with existing literature that shows that ethnic minorities and refugees experience more involuntary admissions than the general population in Canada [46, 47] and Western Europe [48, 49]. One possible explanation is the involvement of police in MH crisis calls. Evidence from Ontario found that police are 12 times more likely to refer White people to community-based services than people of colour [50] and more likely to coercively admit people of colour to emergency psychiatric services [51]. Lack of access to services in the community can worsen existing mental illness and lead to MH crises. It is plausible that poorer access to community-based MH services places immigrant youth at a higher risk for MH crises. At times of crisis, police involvement places them at higher risk of involuntary admission.
Observed trends over time showed that the use of community-based MH services increased following the COVID-19 pandemic for all youth, while emergency department visits and hospitalization for MH dropped immediately after the start of the pandemic but increased shortly after. A similar trends were observed in Ontario [52],[53]. This may reflect closure of facilities and avoidance of care to reduce risk of COVID-19 infection from healthcare settings.
We consistently observed a decline in community-based MH service use for all youth during the summer months across the study years. The uptake of community-based MH service use during the school months may reflect support from teachers and school counsellors in connecting students with community-based services [54, 55].
This study has several limitations. We cannot capture specific ethnicity or racialization with administrative data. Studies in western countries found that MH service interactions vary by ethnicity and/or racialization [56–58]. We cannot measure individual-level income or household income with the databases used in this study. Neighbourhood income quintiles may not reflect individual income. Administrative data is limited to capturing publicly covered services. Therefore, we cannot capture psychosocial services paid out-of-pocket, covered by employment insurance, or provided by salaried professionals such as services delivered by psychologists, counsellors, or peer-support workers. We could not examine service use among immigrants with temporary and precarious status, including refugee claimants and convention refugees who do not yet have permanent resident status, students, and people with work permits, who may face even more profound barriers to needed care.
To the best of our knowledge, there are currently no studies comparing the relationship between income and MH service by immigration among youth in the province of British Columbia, Canada. Using population-based linked administrative data allowed us to capture a large cohort and their interaction with community-level services, hospitals, and emergency departments. Future studies should investigate factors that could explain variations in community-based service use by neighbourhood income quintiles among immigrant youth, as they differ from the patterns observed in non-immigrant youth. The immigrant landscape is also changing in Canada, and continued research in this field is needed to update findings with new groups of immigrants entering the country as service use varies by immigrant subgroups.