Health Reports
Who is reaching out for help? Examining access to mental health and substance use health supports among girls and young women in Canada

Abstract

Background

Girls and young women experience poorer mental health than boys and young men, although the reverse is true for substance use disorders. Few population-based studies examine girls’ and young women’s experiences accessing and receiving mental health and substance use (MHSU) health care support, particularly across sociodemographic groups.

Data and methods

Data from the 2022 Mental Health and Access to Care Survey were used to estimate the proportions of girls and young women who met the criteria for at least one MHSU disorder and who accessed formal MHSU health supports. The types of supports accessed, reasons for not accessing services, and associations between sociodemographic characteristics and the likelihood of indicating that the supports they accessed were helpful were examined. Girls and women aged 15 to 29 were studied, with an analytical sample of 1,254.

Results

Among girls and young women aged 15 to 29, 38.5% met the criteria for one or more MHSU disorders in 2022; of those, 54.6% had accessed formal MHSU health supports. Lesbian and bisexual girls and young women with an MHSU disorder were more likely to access formal supports and more likely to have found the supports helpful compared with their heterosexual peers. Racialized girls and young women were less likely than their non-racialized peers to report the care they received was helpful.

Interpretation

Some sociodemographic differences in the experiences of girls and young women accessing and receiving formal care for MHSU disorders were observed. Results indicated a need to improve the accessibility of formal MHSU supports for this population.

Keywords

access to care; mental disorders; mental health services; women’s health; substance use disorders; substance use health services; adolescent; young adult

Authors

Kristyn Frank and Mila Kingsbury are with the Health Analysis Division at Statistics Canada. Elizabeth Richards is with the Strategic Analysis, Publications, and Training Division at Statistics Canada.

 

What is already known on this subject?

• The prevalence of mood and anxiety disorders has been increasing among Canadian youth in recent years, particularly during the COVID-19 pandemic.
• Gender differences exist in the prevalence of mental health and substance use (MHSU) disorders. Girls and women are more likely to experience mood and anxiety disorders than men and boys, while men and boys are more likely to have substance use disorders.
• Previous studies have found sociodemographic factors, such as gender, immigrant status, and racial and ethnic minority background, to be associated with inequalities in accessing mental health care in Canada, while gender and age have been found to be associated with differences in accessing substance use health services.

What does this study add?

• Just over half of girls and women aged 15 to 29 who met the criteria for at least one MHSU disorder (generalized anxiety disorder, bipolar disorder, social phobia, alcohol and substance dependence) accessed formal health supports in 2022.
• Lesbian and bisexual girls and young women with an MHSU disorder were more likely than their heterosexual peers to report that the supports received helped “a lot,” while racialized girls and young women were less likely than their non-racialized peers to report the supports received were helpful.
• Girls and young women reported both personal reasons, such as preferring to self-manage symptoms and being too busy to seek support, and systemic reasons, such as affordability of services and not knowing how or where to seek formal health supports, for not accessing formal MHSU health services. These findings indicate a need to better inform girls and young women about how to access MHSU health supports and improve the affordability of services for this population.

Introduction

The mental health of youth in Canada has been an increasing concern in recent years, with increases in the prevalence of mood and anxiety disorders among those aged 12 to 24 between 2011 and 2018, particularly among adolescent females.^Note 1 However, trends are not as clear with respect to substance use-binge drinking has decreased for young males, while the use of cannabis and illicit drugs has generally remained stable among this population.^Note 1 These findings broadly align with trends for the general population of Canada between 2012 and 2022.^Note 2

The COVID-19 pandemic also resulted in a decline in mental health among young Canadians,^Note 3, ^Note 4, ^Note 5 with those in low-income neighbourhoods and urban areas, as well as transgender, non-binary, or gender-diverse youth showing worse outcomes than their peers.^Note 6, ^Note 7, ^Note 8, ^Note 9 Some studies have also suggested that there have been increases in substance use during this time; however, results have been inconsistent across studies.^Note 10 Consequently, there are concerns over the barriers young Canadians face in accessing mental health and substance use (MHSU) health supports, particularly those from more vulnerable groups.^Note 11

Gender differences exist in the prevalence of MHSU disorders. Women are more likely than men to experience social anxiety and mood disorders,^Note 12, ^Note 13, ^Note 14 whereas men comprise most cases of substance use disorders.^Note 15, ^Note 16 Cross-national research also reveals that girls have poorer mental health than boys in childhood and adolescence, indicating a need to better understand the experiences of girls and young women.^Note 17 Canadian women younger than 25 years are also more likely than men to report affordability and not knowing where or how to get help as barriers to accessing MHSU health care.^Note 18

A key aspect of improving knowledge of girls’ and young women’s experiences with MHSU disorders is determining whether they are accessing formal health supports. Typically, family doctors are the first point of contact for many Canadians seeking mental health care^Note 19 and represent the “first tier” of mental health services, which can be billed to public health insurance.^Note 20 Consequently, primary care is more accessible to the general population, while patients are referred to specialized MHSU services only when there is a need that cannot be addressed by primary care.

Generally, individuals’ use of health care services is influenced by their sociodemographic characteristics,^Note 21, ^Note 22 and gender is a key factor in predicting service use.^Note 23 Immigrant or refugee status,^Note 21, ^Note 24 being a member of a racialized group,^Note 25, ^Note 26 or having lower income ^Note 20, ^Note 26 are also associated with a lower likelihood of accessing care in Canada, while women are generally more likely to access MHSU health services than men.^Note 23, ^Note 27 Older individuals are also less likely than younger individuals to access substance use health services.^Note 28

Among the youth population, difficulties accessing MHSU health supports specifically have been attributed to individual factors, such as fear of social stigma and perceived confidentiality issues, and systemic factors, such as financial costs, delays in receiving care, or difficulties transitioning from child-focused to adult systems of care.^Note 11, ^Note 29, ^Note 30 Gender, immigrant status, income, and racial and ethnic minority background are also associated with inequalities in accessing MHSU health care in Canada.^Note 21, ^Note 25 Marginalized groups can experience greater difficulty accessing appropriate MHSU health care and sometimes differ in how they experience the stigma of mental illness.^Note 31 Lesbian, gay, and bisexual (LGB) youth may be at particular risk because of social stigma and discrimination,^Note 32 which contribute to higher rates of mental health disorders in this population.^Note 33, ^Note 34 However, while the LGB population generally experiences greater barriers to mental health care, Canadian research indicates they are more likely to use these services than heterosexual individuals.^Note 35, ^Note 36

Given variations in the rates of MHSU disorders among different sociodemographic groups, more information on the treatment gaps and difficulties in accessing care among youth is needed. Additionally, while studies have found that older age and better health status are associated with higher satisfaction with the services received,^Note 27, ^Note 37 little attention has been given to young patients’ satisfaction with MHSU health supports.

This study examines whether predisposing characteristics such as immigrant status, population group, rural or urban status, sexual orientation, and neighbourhood income level are correlated with the prevalence of MHSU disorders, access to formal health supports, and satisfaction with these supports among girls and young women in Canada. Specifically, the study aims to:

1. estimate the proportion of girls and women aged 15 to 29 who met the criteria for any MHSU disorder in the past year, examining differences by sociodemographic characteristics
2. estimate the proportion of these girls and women who accessed formal health supports and describe their use of these supports across sociodemographic groups
3. examine whether girls and young women who met the criteria for any MHSU disorder and accessed formal health supports found them helpful, across sociodemographic groups.

Method

Data source

Data are from the 2022 Mental Health and Access to Care Survey (MHACS), a survey of the mental health of Canadians aged 15 and older living in the 10 provinces. The sampling frame was respondents to the long-form census. The target population was stratified by age group (15 to 24 years, 25 to 44 years, 45 to 64 years, and 65 years and older), gender (female, male), and population group (South Asian, Black, Chinese, Filipino, and other). Respondents answered survey questions using an online electronic questionnaire, led by a trained interviewer over the telephone. Response rates were 20.2% among women and girls aged 15 to 24 and 25.0% among women aged 25 to 44 years. The analytical sample comprised 1,254 girls and women aged 15 to 29.

Measures

Gender: Respondents self-reported their sex at birth (response options “male” or “female”) and their gender (response options “male,” “female” or “or please specify”). The sample for the present study included those who identified their gender as female.

Mental health and substance use: Symptoms of a major depressive episode, generalized anxiety disorder, bipolar disorder, social phobia, and alcohol and substance dependence during the past year were assessed using a modified version of the World Health Organization Composite International Diagnostic Interview. For the present study, respondents who met criteria for any of these disorders in the past 12 months, as identified by the MHACS algorithm, were examined.

Formal mental health support: Participants were asked whether they had talked to a list of people about problems with their emotions, mental health, or substance use. For the present study, talking to a psychiatrist, family doctor, psychologist, nurse, or social worker, and being hospitalized or accessing online therapy, were considered forms of formal MHSU health support. For each provider type they talked to, respondents were asked, “In general, how much would you say the [provider] helped you (for your problems with your emotions, mental health, or use of alcohol or drugs)?” A binary variable was created comparing those who indicated the provider helped “a lot” with the those who reported the provider helped “some,” “a little,” or “not at all.” For girls and women who spoke with more than one type of provider, the help rating for the provider they reported seeing the most often was used.

Unmet need: Respondents were asked whether they received the following types of help during the past 12 months “because of problems with [their] emotions, mental health or use of alcohol or drugs”: information about problems, treatments, or available services; medication; or therapy or counselling. Those who had not received these forms of help were asked about their perceived needfor each type of help. Those who indicated they had not received each type of help but needed to were asked to select the reasons they did not receive each form of help needed from a list of options.

Several characteristics were considered as predictors of MHSU disorders, including age group (15 to 19 years, 20 to 23 years, 24 to 29 years), residence in rural areas versus population centres, and immigrant status (born in Canada, born outside of Canada). Respondents reported their sexual orientation (“heterosexual,” “lesbian or gay,” “bisexual,” or “or please specify”). For analytical purposes, a binary variable was created comparing participants who identified as heterosexual with those who identified as lesbian or gay, bisexual, or another orientation. Respondents reported their membership to racialized population groups, categorized for analysis as follows: South Asian, Chinese, Black, Filipino, other or multiple racialized minority groups, or not a member of a racialized group. For some analyses, racialized population groups were combined because of small cell sizes in each category. While respondents also reported their Indigenous identity (First Nations, Métis, Inuit, or not an Indigenous person), data could not be released for Indigenous people because of small sample sizes. Indigenous participants were therefore excluded from the analyses. Finally, neighbourhood income was used as a proxy for socioeconomic status, given concerns that personal or household income may not accurately reflect this concept for youth aged 15 to 29. Neighbourhood income decile (per census metropolitan area) was derived from participants’ postal codes. Categories were collapsed into three groups for the analysis-“low” (three lowest deciles), “middle” (four middle deciles), and “high” (three highest deciles).

Analysis

Crosstabulations and Rao-Scott chi-square tests were used to compare the proportions of girls and women meeting criteria for an MHSU disorder and seeking formal support across sociodemographic groups. Logistic regression was used to estimate the odds of accessing formal MHSU health supports among those who met the criteria for at least one MHSU disorder, from sociodemographic characteristics (entered simultaneously into the model). A second set of logistic regression models estimated the odds of receiving information, medication, and therapy from demographic predictors. Finally, a third logistic regression model was used to estimate the odds of reporting that formal services helped “a lot,” from sociodemographic predictors. Analyses were weighted using survey weights, based on inverse probability of selection and adjusted for survey non-response, as well as bootstrap weights with 1,000 resamples.

Results

Characteristics of girls and young women who met the screening criteria for at least one mental health or substance use disorder

Overall, just under 4 in 10 women and girls (38.5%) aged 15 to 29 met the screening criteria for one or more of the assessed MHSU disorders (major depressive episode, generalized anxiety disorder, bipolar disorder, social phobia, alcohol use disorder, or substance use disorder) in 2022 (Table 1).



No statistically significant differences were observed in the proportion of girls and young women who met the screening criteria for at least one MHSU disorder by area of residence, immigrant status, population group, or neighbourhood income tertile. Notably, lesbian and bisexual girls and young women were statistically more likely than their heterosexual peers to have met the criteria for at least one MHSU disorder. Over 6 in 10 lesbian and bisexual girls and women aged 15 to 29 met the criteria for an assessed MHSU disorder (63.8%) compared with nearly one-third of heterosexual girls and women in this age group (32.1%).

Access to formal mental health and substance use health care supports among girls and young women

Over half of girls and young women who met the screening criteria for at least one MHSU disorder reported accessing formal health supports (54.6%, Table 2). Although some variation was observed across sociodemographic characteristics, most were not statistically significant. One exception was for sexual orientation-lesbian and bisexual girls and young women who met the criteria for an MHSU disorder were more likely to access health care services (69.6%) compared with their heterosexual peers (46.7%).



A logistic regression model (results not shown) was also estimated to examine the unique contribution of each sociodemographic factor examined in Table 2. Only sexual orientation had a statistically significant relationship with accessing health care supports when accounting for the other characteristics. That is, lesbian and bisexual young women and girls who met the criteria for an MHSU disorder were more likely than their heterosexual counterparts to access health services.

Types of help received and reasons for not accessing mental health and substance use health supports

Most girls and young women who met the criteria for at least one MHSU disorder and accessed formal health services about a problem with their emotions, mental health, or substance use consulted a family doctor or general practitioner (63.2%, Chart 1). Smaller proportions consulted a social worker or counsellor (41.1%), a psychologist (33.4%), a psychiatrist (26.8%), or a nurse (13.2%) about their disorder.

Description of Chart 1



Data table for chart 1
Table summary
This table displays the results of Data table for chart 1 Percent and 95% confidence interval (appearing as column headers).

	Percent	95% confidence interval
		lower	upper
Family doctor or general practitioner	63.2	54.8	70.9
Social worker or counsellor	41.1	33.0	49.8
Psychologist	33.4	25.6	42.2
Psychiatrist	26.8	20.2	34.7
Nurse	13.2	8.5	20.0
Note: Percentages do not sum to 100% because respondents could select more than one type of health care provider. Source: Mental Health and Access to Care Survey, 2022.

Nearly half of girls and young women who met the screening criteria for at least one MHSU disorder reported that they had received counselling or therapy (49.2%; 95% confidence interval [CI]: 43.0, 55.3), while over 3 in 10 had received information (34.9%; CI: 29.5, 40.7) or medication (30.7%; CI: 25.2, 36.7). Among this group, the likelihood of receiving counselling or therapy because of problems with emotions, mental health, or substance use was not significantly different by age group, immigrant status, population group, or neighbourhood income (Table 3). However, sexual orientation was associated with differences in care-lesbian and bisexual girls and young women who met the criteria for an MHSU disorder were more likely than their heterosexual counterparts to have received counselling or therapy because of problems with their emotions, mental health, or substance use (odds ratio [OR]: 2.19).



Similarly, lesbian and bisexual girls and young women who met the criteria for an MHSU disorder were more likely than their heterosexual peers to have received medication because of problems with their emotions, mental health, or substance use (OR: 3.65). Additionally, women aged 20 to 23 (OR: 2.14) and 24 to 29 (OR: 2.38) were more likely than girls and young women aged 15 to 19 to have received medication, while immigrant girls and young women (OR: 0.19) were less likely than girls and young women born in Canada to have received medication. No statistically significant differences were observed across sociodemographic groups for girls and young women who received information for problems with their emotions, mental health, or substance use.

The top reasons for not accessing information among those who needed it included unawareness of how or where to seek the information needed (46.3%), being too busy (33.9%), affordability of services (31.6%), and preference to self-manage (29.4%). About one-quarter reported help was not readily available (26.7%), or that they had no confidence in the health care system (24.0%). About 2 in 10 indicated they did not access information because their insurance would not cover it (20.2%). Although access to information is generally free, this finding may be an indication of low mental health literacy among this population. Note that these results should be used with caution because of small sample sizes for this measure, which may compromise data quality.

The most common reasons for not accessing counselling or therapy included a preference to self-manage (39.2%), therapy being unaffordable (37.2%), unawareness of where to get this kind of help (36.2%), and being too busy to seek this type of support (33.9%). Barriers to counselling or therapy were also related to the health care system, such as not having confidence in the system (25.8%), help not being readily available (24.8%), and insurance not covering the service (20.2%). Results for the reasons girls and young women who met the criteria for an MHSU disorder and reported a need for medication but did not access this support are not presented because of poor data quality for this measure (small sample size).

Characteristics associated with reporting whether the formal health care services accessed were helpful

Sociodemographic differences in the likelihood of girls and young women with an MHSU disorder reporting that the service provider they spoke with the most often helped them “a lot,” versus “some,” “a little,” or “not at all,” are presented in Table 4. Girls and young women aged 20 to 23 years who met the criteria for an MHSU disorder and accessed formal health services were significantly more likely (OR: 3.85) than their counterparts aged 15 to 19 years to report the services had helped a lot.



Girls and young women with an MHSU disorder who were members of a racialized group were significantly less likely (OR: 0.24) than their non-racialized peers to report that their use of health services helped a lot. Additionally, lesbian and bisexual girls and young women who met the criteria for an MHSU disorder were significantly more likely (OR: 2.49) than their heterosexual peers to report that the health care services they accessed helped a lot.

Discussion

Overall, nearly 4 in 10 girls and young women aged 15 to 29 met the criteria for at least one MHSU disorder, higher than in the general Canadian population, where fewer than 2 in 10 individuals aged 15 and older met the criteria for an MHSU disorder in 2022.^Note 2 Just over half of girls and young women who met the criteria for any MHSU disorder had accessed formal health care services. While previous literature indicates that immigrants, racialized groups, and low-income individuals are less likely to access health services than non-immigrants, non-racialized, and higher income groups, respectively,^Note 20, ^Note 21, ^Note 25 this study found no statistically significant differences between these groups. However, this may be attributable to the small sample size of girls and young women with an MHSU disorder in the MHACS, which resulted in large confidence intervals.

The most common type of provider consulted by girls and young women who met the criteria for an MHSU disorder was a family doctor or general practitioner, followed by a social worker or counsellor; smaller proportions consulted with a psychologist or psychiatrist. This aligns with results for the broader population aged 15 and older^Note 2 and previous research, which finds that patients typically consult family doctors first when seeking formal MHSU health services.^Note 19 These results likely reflect the greater accessibility of primary care services as they are billed to public health insurance programs, and the fact that patients are typically referred to specialized mental health care providers only if there is a need for services that cannot be addressed by primary care.^Note 20

About half of girls and young women who met the criteria for an MHSU disorder reported receiving counselling or therapy, while smaller proportions received information or medication. Respondents who met the criteria for an MHSU disorder and did not access information indicated individual reasons, such as being too busy or a preference to self-manage, as well as systemic reasons, such as lack of affordability and unawareness of how or where to access services. The preference to self-manage symptoms might be a means to reduce social stigma or a strategy used while waiting for treatment from formal health care providers.^Note 38 Similar reasons were reported for not accessing therapy or counselling, pointing to a need to provide girls and young women with more information about how to access MHSU supports and to improve the accessibility of these services for youth.

Sociodemographic differences in meeting criteria for a mental health or substance use disorder and accessing formal health care services

Consistent with previous literature,^Note 39, ^Note 40 a higher proportion of lesbian or bisexual girls and young women met the criteria for an MHSU disorder compared with their heterosexual peers. This difference is often explained by the minority stress model, which proposes that sexual minority groups experience worse mental health outcomes because of a higher likelihood of experiencing social stigma, discrimination, and harassment than their heterosexual peers.^Note 33, ^Note 34 Echoing previous Canadian studies,^Note 35, ^Note 36 lesbian or bisexual girls and young women who met the criteria for an MHSU disorder were more likely to access health services than their heterosexual peers. However, it should be noted that earlier studies have found LGB+ groups generally encounter greater barriers to health care than heterosexual individuals.^Note 41, ^Note 42, ^Note 43

Greater use of formal health services among lesbian and bisexual girls and young women with MHSU disorders might be due to a greater severity of MHSU symptoms among LGB+ individuals compared with their heterosexual peers.^Note 32 Lesbian and bisexual girls and young women with MHSU disorders were also more likely to have received therapy or counselling and medication than their heterosexual counterparts, which again may reflect differences in the severity of symptoms between LGB and heterosexual populations, leading to different types of treatment.

Immigrant status also mattered. Similar to previous research,^Note 44 immigrant girls and young women with MHSU disorders were less likely to receive medication compared with their Canadian-born peers. This may reflect unique barriers that immigrants experience when accessing MHSU services, such as difficulties speaking an official language, navigating a new health system, or finding culturally appropriate services.^Note 45, ^Note 46 Additionally, some immigrant groups may not have universal health care coverage upon arriving in Canada^Note 47 or experience greater fear of social stigma related to perceptions of MHSU disorders in their source countries, preventing them from receiving medication.

Among girls and young women who met the criteria for an MHSU disorder and accessed formal health care services, racialized individuals were less likely than their non-racialized peers to indicate that the services helped a lot. This could be attributable to a lack of health care providers trained in culturally appropriate health care, which addresses issues unique to racialized groups.^Note 48 Patients from minority groups often report race and ethnicity as important to their mental health and are less satisfied with treatment when these issues are not addressed by their health care provider.^Note 49 Therefore, these results may indicate a need to provide Canadian health care providers with more cultural competency and sensitivity training, such as recognizing how racialized individuals may have unique stressors affecting their mental health.

Limitations

Data from the MHACS were collected during the COVID-19 pandemic, therefore, the estimated prevalence of MHSU disorders among girls and young women may not be comparable to research findings from other time periods. Since the study was restricted to girls and young women aged 15 to 29, some characteristics previously found to be predisposing factors in accessing health care, such as education level, marital status, and income, were not examined because they might not be applicable to the youngest respondents. Neighbourhood income level was also used as a proxy to estimate differences in respondents’ socioeconomic status. Moreover, previous research indicates that parental and familial characteristics are key factors in youths’ access to mental health services.^Note 21, ^Note 50 However, information on respondents’ parents or family structure was unavailable.

Because of the small sample size, some estimates had wide confidence intervals, indicating low precision. This limits the assessment of statistical differences between subgroups. Additionally, some sociodemographic characteristics, such as Indigenous identity and region of residence, were not included because of data quality concerns related to small sample sizes. Disaggregation of population groups was also limited because of small sample sizes, since racialized groups had to be combined to obtain adequate sample sizes when examining girls and young women with an MHSU disorder. Also, since MHSU disorders were grouped together, potential differences between individuals with different types of disorders may be masked.

The severity of individuals’ MHSU disorders could not be examined. While the MHACS data provide information on one aspect of severity-the degree to which various MHSU disorders affected activities such as home, school, or work responsibilities-the small sample size of girls and young women prevented further disaggregation for these measures. This information could be helpful in determining why some groups of girls and young women with MHSU disorders are more likely to access formal health services or more likely to receive certain types of treatment. Future research in this area would be beneficial.

Conclusion

Increases in the prevalence of MHSU disorders among Canadian youth have raised concerns over their access to formal health care services. This study provided a detailed examination of the experiences of girls and women aged 15 to 29 in Canada. Notably, lesbian and bisexual girls and young women were more likely than their heterosexual peers to meet the criteria for at least one MHSU disorder, access health care services, and receive counselling or therapy and medication. Immigrant girls and young women who met the criteria for an MHSU disorder were less likely than their Canadian-born peers to receive medication. Among individuals who met the criteria for at least one MHSU disorder, lesbian and bisexual girls and young women were more likely to report that the services they received were helpful compared with their heterosexual peers, while racialized girls and young women were less likely than their non-racialized peers to report that the services they received were helpful.

Both personal and systemic reasons were reported for not accessing mental health care services, indicating a need to improve the accessibility of services for Canadian youth and better inform them about how to obtain MHSU health services. Findings from this study can inform health care providers, policy makers, and community organizations about treatment gaps and barriers to care among different groups of Canadian girls and young women with MHSU disorders.