Ethnic Differences in Mental Health Status and Service Utilization in Ontario, Canada

This study compares the prevalence of self-reported mental health factors, mental health service use, and unmet needs across the 4 largest ethnic groups in Ontario, Canada: white, South Asian, Chinese, and black groups.

OriginalResearch
Ethnic Differences in Mental Health Status
and Service Utilization: A Population-Based
Study in Ontario, Canada
Diffe´rences ethniques de l’e´tat de sante´ mentale et de
l’utilisation des services une e´tude dans la population
en Ontario, Canada
Maria Chiu, MSc, PhD1,2
, Abigail Amartey, MPH3, Xuesong Wang, MSc3,
and Paul Kurdyak, MD, PhD, FRCPC1,2,4
Abstract
Background:The purpose ofthis study was to compare the prevalence ofself-reported mentalhealth factors,mental
health service use, and unmet needs across the 4 largest ethnic groups in Ontario, Canada: white, South Asian
black groups.
Methods: The study population was derived from the Canadian Community Health Survey, using a cross-sectio
254,951 white,South Asian,Chinese,and black residents living in Ontario,Canada,between 2001 and 2014.Age- and sex-
standardized prevalence estimates for mental health factors, mental health service use, and unmet needs wer
each of the 4 ethnic groups overalland by sociodemographic characteristics.
Results: We found that self-reported physician-diagnosed mood and anxiety disorders and mentalhealth service use were
generally lower among South Asian,Chinese,and black respondents compared to white respondents.Chinese individuals
reported the weakest sense of belonging to their local community and the poorest self-rated mental health an
likely to report suicidal thoughts in the past year as white respondents. Among those self-reporting fair or poo
less than half sought help from a mentalhealth professional,ranging from only 19.8% in the Chinese group to 50.8% in th
white group.
Conclusions:The prevalence ofmentalhealth factors and mentalhealth service use varied widely across ethnic groups.
Efforts are needed to better understand and address cultural and system-level barriers surrounding high unme
identify ethnically tailored and culturally appropriate clinicalsupports and practices to ensure equitable and timely menta
health care.
Abre´ge´
Contexte : Le but de cette e´tude e´tait de comparer la pre´valence des facteurs de sante´ mentale auto-de´clare´s, de l’utilisation
des services de sante´ mentale, et des besoins non comble´s dans les quatre groupes ethniques les plus nombreux de l’Onta
Canada:les groupes blancs,sud-asiatiques,chinois et noirs.
1 MentalHealth and Addictions Program,Institute for ClinicalEvaluative Sciences,Toronto,Ontario
2 Institute of Health Policy,Management and Evaluation,University of Toronto,Toronto,Ontario
3 Institute for ClinicalEvaluative Sciences,Toronto,Ontario
4 Health Outcomes and Performance Evaluation (HOPE),CAMH, Toronto,Ontario
Corresponding Author:
Maria Chiu,MSc,PhD,MentalHealth and Addictions Program,Institute for ClinicalEvaluative Sciences,G-106,2075 Bayview Avenue,Toronto,Ontario,
M4N 3M5,Canada.
Email:[e-mail]
The Canadian Journalof Psychiatry /
La Revue Canadienne de Psychiatrie
2018,Vol.63(7) 481-491
ª The Author(s) 2018
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0706743717741061
TheCJP.ca | LaRCP.ca
Canadian
Psychiatric Association
Association des psychiatres
du Canada

Me´thodes : La population de l’e´tude a e´te´ tire´e de l’Enqueˆte sur la sante´ dans les collectivite´s canadiennes,en utilisant un
e´chantillon transversal de 254 951 re´sidents blancs, sud-asiatiques, chinois et noirs de l’Ontario, Canada, entre 2001 et
Des estimations de la pre´valence, normalise´e selon l’aˆge et le sexe, des facteurs de sante´ mentale, de l’utilisation des services
de sante´ mentale, et des besoins non comble´s ont e´te´ calcule´es pour chacun des quatre groupes ethniques ge´ne´ralement, et
selon les caracte´ristiques sociode´mographiques.
Re´sultats : Nous avons constate´ que les troubles anxieux et de l’humeur diagnostique´s par un me´decin et auto-de´clare´s ainsi
que l’utilisation des services de sante´ mentale e´taient ge´ne´ralement plus faibles chez les re´pondants sud-asiatiques, chinois et
noirs comparativement aux re´pondants blancs. Les personnes chinoises de´claraient le sentiment d’appartenance le plus faible a`
leur communaute´ locale et la moins bonne sante´ mentale auto-de´clare´e, et e´taient presque aussi susceptibles de faire e´tat de
pense´es suicidaires dans l’anne´e e´coule´e que les re´pondants blancs.Parmiceux quide´claraient une bonne ou une mauvaise
sante´ mentale, moins de la moitie´ ont eu recours a` l’aide d’un professionnel de la sante´ mentale, allant de seulement 19,8% du
groupe chinois a` 50,8% du groupe blanc.
Conclusions : La pre´valence des facteurs de sante´ mentale et de l’utilisation des services de sante´ mentale variait beaucoup
entre les groupes ethniques.Il faut des initiatives pour mieux comprendre et aborder les obstacles culturels et syste´miques
auxquels se butent les nombreux besoins non comble´s, et pour identifier les soutiens et pratiques cliniques adapte´s a` l’ethnie
et a` la culture pour leur assurer des soins de sante´ mentale e´quitables en temps opportun.
Keywords
mentalhealth,mentalhealth services,ethnic groups
Mentalillness is increasingly being recognized as a global
public health issue,with an estimated lifetime prevalence
ranging from 18% to 36% worldwide.1 In more diverse jur-
isdictions,such as Ontario,Canada,in which 26% of the
nearly 13 million residents identify as a visible minority,2
understanding how mental health experiences vary across eth-
nic groups living within the same macro-environmentis
important.Few past studies suggest that compared to white
Canadians, Chinese, other Asian,black, and ethnic minority
populations are less likely to reportdepression ormajor
depressive episode,3,4 mentaldistress,5 suicidalthoughts,6,7
and mentalhealth service use3,8-10butare more likely to
report poorer self-rated mental health11 and a weaker sense
of belonging to one’s local community,11,12
which has been
associated with higher levels of depression and poorer mental
health.13,14
Many of these past studies,however,have often
included populations that were limited to 1 or 2 ethnic groups,
immigrant populations, or a combination of multiple ethnici-
ties into a single category.3,8-10,12
Given recent investments
made by the Ontario government to increase funding towards
mental health and addictions services,15a unique opportunity
exists to uncover potentialdifferences in the mentalhealth
status and experiences among the major ethnic minority
groups in Ontario (i.e.,those of South Asian,Chinese,and
black descent) compared with those of white ethnicities.
There is also limited evidence around how unmet needs
for mental health care varies across major ethnic groups in
Ontario, which is particularly important given that previous
literature has identified unmetneeds as a persisting prob-
lem.16 Evidence from studies of populations in the United
States has reported that among those in need of care, Asian
and black populations are less likely to receive mental health
treatment compared to non-Hispanic white individuals.17,18
Literature has often cited barriers such as lack of health
insurance and costs of mentalhealth services for those of
black descent.17,19
Whether similar findings are seen in other
jurisdictions such as Ontario, in which there are less out-of-
pocket costs related to mental health care, is less clear. Pre-
vious studies have noted that unmet needs for mental health
care appear to be higher among ethnic minority individuals
compared to nonimmigrants,longer-term immigrants,and
white Canadians;however,these studies only focused on
specific mentalillness populations.20,21Furthermore,the
role that sociodemographic factors, such as age, income, and
immigrantstatus,play in explaining potentialvariation is
important to understand,as these factors are independently
associated with mental health issues and ethnicity.22,23
It is therefore necessary to explore the interrelationship
between diagnosed psychiatric conditions, self-reported men
tal health issues, and whether needs for mental health care a
being adequately met across ethnic groups. The primary obje
tive of the present study was to compare the prevalence of s
reported 1) mental health status, 2) mental health service us
and 3) unmet needs for care across a population-based samp
of white, South Asian, Chinese, and black Canadians living in
Ontario,Canada.A secondary objective was to examine
whether ethnicity is an independentrisk factor of self-
reported mental health status and mental health service use
Methods
Data Sources and Study Population
The study population was derived from a pooled sample of
participants of Statistics Canada’s cross-sectional Canadian
Community Health Survey (CCHS) from cycles 1.1 (2001),
2.1 (2003), 3.1 (2005), and the CCHS–Annual components for
2007, 2008, 2009, 2010, 2011, 2012, 2013, and 2014 (respon
rates ranged from 75.1% to 94.4%). The CCHS survey waves
482 The Canadian Journalof Psychiatry 63(7)

were combined using the pooled approach without rescaling of
sampling weights as described in Thomas and Wannell.24
Details aboutthe survey methodology are described else-
where.25,26
Briefly, these surveys used a consistent multistage
stratified cluster sampling strategy to collectself-reported
sociodemographic and health-related information from a rep-
resentative sample of persons in private dwellings.
In this study,we analyzed people living in Ontario who
were aged 12 years or older and who identified themselves as
white, Chinese, South Asian (i.e., those of Indian, Pakistani,
Bangladeshi,or Sri-Lankan origin),or black.Those who
responded with other or multiple ethnicities were excluded
from the study population.
Study Variables
Sociodemographic characteristics included ethnicity,age,
sex, marital status, highest level of education attained by the
individual,annualhousehold income in Canadian dollars,
living in a broader urban area, and immigrant status.
We analyzed mental health-related factors that were col-
lected consistently across CCHS survey waves using all
years for which the data were available.Mentalhealth–
related factors included fair or poor self-rated mental health
(compared to good,very good, and excellent),lifetime and
past-year suicidal ideation (i.e., suicidal thoughts), and very
weak or somewhat weak sense of belonging to one’s local
community (compared to very strong and somewhat strong).
In addition to self-reported factors related to mental health,
we also examined self-reported lifetime physician-diagnosed
mood disorder (e.g.,depression or bipolar disorder) and
anxiety disorder(e.g.,obsessive-compulsive disorderor
panic disorder) and mental health service use (i.e.,seen or
talked to a health professionalaboutemotionalor mental
health) in the past12 months and from whom individuals
received care: family doctor, psychiatrist, allied health (i.e.,
psychologists,nurses,and socialworkers or counsellors),
and other health professionals. Last, to explore unmet needs
for care, we examined mental health service use within the
past year among individuals reporting 1) past-year suicidal
ideation or 2) fair or poor self-rated mentalhealth.The
CCHS surveys examined in this study only asked about
mentalhealth service use in the pastyear.Therefore,we
chose to explore service use among individuals reporting
current or past-year mental health issues—this is in contrast
to the self-reported diagnosed mood and anxiety disorders
measures, which assessed lifetime diagnoses.
StatisticalAnalyses
We calculated the crude prevalence of sociodemographic
characteristics and age- and sex-standardized prevalence of
mental health–related factors and mental health service use
in each of the 4 ethnic groups using the indirect standardiza-
tion method and 2001 to 2014 Ontario CCHS respondents as
the standard population.Indirectstandardization uses age-
and sex-specific rates from a standard population to calcul
the expected number of events in a study population by us
the age and sex distribution of the study population.27Esti-
mates were further stratified by sex, age (12-24, 25-64, 65
years), and immigrant status (immigrant vs. nonimmigrant
to investigate ethnic variations within these relevant
dimensions.Preliminary analysis showed no significant
differences in the prevalence of mental health factors and
mental health service use between recent immigrants (les
than 10 years in Canada) and long-term immigrants (10 or
more years in Canada) across ethnic groups; therefore, we
present results for immigrant versus nonimmigrant.
Missing values formentalhealth factors and mental
health service use variables (4.8% missing for allvari-
ables) were excluded when calculating prevalence estimat
We also performed logistic regression to compare the
associations between ethnicity and the prevalence of3
self-reported outcomes:fair or poor mentalhealth,diag-
nosed mood or anxiety disorder, and past-year mental hea
service use. Crude, age- and sex-adjusted, and multivariat
adjusted odds ratios controlling for potentialconfounders,
including age, sex, income, education, immigrant status, a
CCHS survey year,were calculated.Odds ratios were pre-
sented for South Asian, Chinese, and black individuals with
white individuals as the reference group.
Statisticalanalyses were performed using the SAS v9.4
statistical software (SAS Institute,Cary,NC). All analyses
were weighted by Statistics Canada’s sample weights to
accountfor the complex survey sampling design and to
improve generalizability of the estimates. Bootstrap metho
were used to test statistical significance with the 95% con
fidence interval (CI) defined as the 2.5th and 97.5th percen
tiles of the 500 bootstrap rates or the natural logarithm of
ratios.The P values comparing ethnic-specific prevalence
estimates and odds ratios to the reference white populatio
were derived from the standard z test, in which the rate or
logarithm of the rate ratio was divided by the standard dev
tion of this statistic across the 500 bootstrap samples.All
tests were 2-sided, and P < 0.05 (or nonoverlapping 95% C
when available) was considered statistically significant.
Our study was approved by the Research Ethics Board a
Sunnybrook Health Sciences Centre. Informed consent was
obtained by Statistics Canada from all study participants.
Results
Study Population and Demographics
Our study population consisted of 238,392 white, 6779 Sou
Asian, 5073 Chinese,and 4707 black respondents.The
weighted proportions of the 4 ethnic groups in the CCHS
sample were representative of these groups in the overall
Ontario census population.2 The 3 ethnic minority groups
were younger than the white population,with mean ages
ranging from 37.8 to 40.4 years compared with 44.7 years
white respondents (Table 1). Most respondents lived in urb
La Revue Canadienne de Psychiatrie 63(7) 483

areas and had more than a high school education. Compared
to white respondents, nonwhite respondents were less likely to
have an annualincome of $60,000 or more,and a greater
proportion reported being of immigrant status.
MentalHealth Factors
Overall. We found marked ethnic differences in mental health
factors.Chinese respondents had the weakestsense of
belonging (49.5%)and poorestself-rated mentalhealth
(7.5%) compared to all other ethnic groups (Table 2). Con-
versely,South Asians had the strongest sense of belonging
(28.2%),and black individuals showed no difference com-
pared to the white population.South Asian,Chinese,and
black respondents were significantly less likely to report
eitherlifetime suicidalideation orlifetime diagnosis of
mood or anxiety disorder compared to white respondents;
however, for past-year suicidal ideation, no statistically sig-
nificantdifference was found between Chinese and white
respondents (1.6% vs. 1.9%, respectively).
By age and sex.Similar to overall rates,sense of belonging
was the weakest among Chinese respondents and generally
stronger among South Asian respondents, irrespective of sex
and across mostage groups (Table 2,Appendix Table 1).
The highestprevalence of fair or poor self-rated mental
health was among Chinese adults aged 65þ years.In gen-
eral,lifetime suicidalideation and self-reported diagnosed
mood or anxiety disorders were significantly lower among
most ethnic minority groups, irrespective of age and sex.
By immigrant status.White and Chinese immigrants reported
significantly higher rates of weak sense of belonging com-
pared to their Canadian-born counterparts (Table 3). Regard-
less of immigrant status,ethnic minority groups reported a
lower prevalence of mood or anxiety disorders compared to
white people.However,Chinese immigrants reported the
highestprevalence of poor self-rated mentalhealth (8.2%)
compared to other immigrant groups. The prevalence of life-
time suicidal ideation was lower among all ethnic minority
immigrants and Chinese and South Asian nonimmigrants
compared to their white counterparts.
MentalHealth Service Use Overalland among Those
in Need
White respondents were significantly more likely to use
mental health services in the past year compared to ethnic
minorities,irrespective of age,sex,and immigrantstatus
(Tables 3 and 4; Appendix Table 1). White and South Asian
individuals were significantly more likely to see their family
doctors for their mental health services than any other pro-
fessional; however, Chinese respondents were just as likely
to see a family doctor,psychiatrist,or allied health profes-
sional,and black respondents were similarly likely to see
their family doctor or allied health professional.
Among those self-reporting fair or poor mentalhealth,
only half of respondents sought help in the past year.This
percentage was particularly low among the nonwhite ethnic
groups, including only 14% of Chinese respondents. Among
individuals reporting suicidalthoughts in the pastyear,
Table 1. Prevalence of Sociodemographic Characteristics,by Ethnic Group,Ontario,Canada,2001 to 2014.a
White (n ¼ 238,392)South Asian (n ¼ 6779)Chinese (n ¼ 5073) Black (n ¼ 4707)
% % Pb % Pb % Pb
Age,mean,y 44.7 37.8 <0.001 40.4 <0.001 38.0 <0.001
Sex,male 49.0 51.3 <0.01 48.7 0.76 45.8 <0.01
Maritalstatus
Divorced/separated 7.2 2.9 <0.001 3.0 <0.001 12.6 <0.001
Widowed 5.4 2.3 <0.001 3.7 <0.001 2.1 <0.001
Single,never married 28.0 32.0 <0.001 33.7 <0.001 46.7 <0.001
Common-law/married 59.4 62.9 <0.001 59.6 0.82 38.6 <0.001
Highest levelof education
High schoolgraduation or less 40.5 37.0 <0.001 36.0 <0.001 40.1 0.67
More than high school 59.5 63.0 <0.001 64.0 <0.001 59.9 0.66
Annualhousehold income,mean,$ 86,397.2 71,851.1 <0.001 74,971.1 <0.001 59,844.2 <0.001
Income group
<$30,000 14.4 17.0 <0.001 18.3 <0.001 26.9 <0.001
$30,000 to <$60,000 25.3 33.7 <0.001 27.6 <0.01 33.6 <0.001
$60,000 60.3 49.3 <0.001 54.1 <0.001 39.5 <0.001
Living in urban area 81.7 98.1 <0.001 98.0 <0.001 97.8 <0.001
Immigrant status
Immigrant 17.7 84.8 <0.001 83.6 <0.001 73.8 <0.001
Canadian born 82.3 15.2 <0.001 16.4 <0.001 26.2 <0.001
aData were derived from the Ontario components of Statistics Canada’s Canadian Community Health Surveys. Estimates were weighted by th
weight.
bBootstrap methods were used to derive P values for comparisons of estimates for nonwhite ethnic groups with estimates for the white popula
484 The Canadian Journalof Psychiatry 63(7)

mental health service use was stilllow with a similar per-
centage of white (53.2%),South Asian (51.4%),and black
individuals (43.6%) reporting seeking help in the past year;
however, Chinese respondents reported a significantly lower
percentage (19.9%) than the white group. It should be noted
that these estimates were based on a small number of ethnic
minorities reporting past-year suicidal ideation.
Odds Ratios
Crude and multivariate odds ratios indicated that compared to
the white reference group,Chinese respondents were signifi-
cantly more likely to report fair or poor self-rated mental health,
while black individuals were significantly less likely to report
this (Figure 1). Prior to adjustment, South Asian individuals had
significantly lower odds of reporting fair or poor self-rated
tal health than white individuals; however, after adjusting
age, sex, and other sociodemographic covariates, the odds
were no longer significant. For the remaining outcome vari
all ethnic minority groups were consistently less likely to h
diagnosed mood or anxiety disorder or a past-year mental
visit compared to the white reference population even afte
trolling for covariates.
Discussion
In this population-based study,we found thatcompared to
ethnic minorities, white individuals had a significantly high
prevalence of lifetime suicidal ideation, physician-diagnose
mood oranxiety disorders,and past-yearmentalhealth
Table 2. Age- and Sex-Standardized Prevalence of MentalHealth Factors,by Ethnic Group and by Sex,Ontario,Canada,2001 to 2014.a
White (n ¼ 238,392) South Asian (n ¼ 6779) Chinese (n ¼ 5073) Black (n ¼ 4707)
Sex,n
Male 107,492 3378 2416 2044
Female 130,900 3401 2657 2663
% (95% CIb) % (95% CIb) % (95% CIb) % (95% CIb)
Somewhat weak/weak sense of belonging
All 33.7 (33.3-34.0) 28.2c (26.5-29.8) 49.5c (46.9-51.2) 35.2 (32.9-37.1)
Male 34.6 (34.2-35.1) 28.6c (26.4-30.7) 52.1c (49.0-54.8) 33.9 (30.9-36.9)
Female 32.8 (32.3-33.3) 27.8c (25.5-30.0) 47.0c (43.2-49.5) 36.2c (33.1-38.9)
Fair/poor self-rated mentalhealth
All 5.6 (5.5-5.8) 4.9c (4.1-5.7) 7.5c (6.4-8.7) 4.7c (3.9-5.7)
Male 5.2 (4.9-5.4) 4.4 (3.4-5.3) 6.2 (4.6-7.7) 4.5 (3.0-6.2)
Female 6.1 (5.8-6.3) 5.4 (4.4-6.7) 8.8c (7.0-10.5) 4.9c (3.9-6.2)
Past-year suicidalideation
All 1.9 (1.7-2.0) 0.9c (0.5-1.4) 1.6 (0.8-2.4) 1.1c (0.6-1.6)
Male 1.6 (1.4-1.7) 1.6 (0.8-2.4) 1.5 (0.5-2.7) 0.9c (0.3-1.6)
Female 2.1 (2.0-2.4) 0.3c (0.1-0.5) 1.7 (0.6-2.8) 1.2c (0.5-2.0)
Lifetime suicidalideation
All 8.7 (8.4-8.9) 3.6c (2.7-4.7) 4.6c (3.5-5.8) 3.6c (2.8-4.6)
Male 7.3 (6.9-7.7) 4.0c (2.6-5.5) 3.9c (2.6-5.5) 2.5c (1.6-3.5)
Female 10.0 (9.5-10.4) 3.2c (2.1-4.5) 5.2c (3.4-7.1) 4.6c (3.3-6.2)
Mood disorder
All 7.9 (7.7-8.1) 3.4c (2.9-4.0) 2.5c (1.9-3.1) 4.3c (3.0-5.1)
Male 5.7 (5.5-6.0) 2.3c (1.7-3.0) 1.9c (1.1-2.7) 2.9c (1.5-4.2)
Female 10.0 (9.7-10.3) 4.5c (3.6-5.5) 3.1c (2.2-4.1) 5.6c (3.9-6.7)
Anxiety disorder
All 6.4 (6.2-6.6) 2.5c (2.0-2.9) 1.5c (1.1-2.0) 3.0c (2.3-3.8)
Male 4.7 (4.5-4.9) 2.1c (1.4-2.7) 0.9c (0.5-1.5) 2.4c (1.2-3.7)
Female 8.1 (7.8-8.4) 2.8c (2.2-3.6) 2.0c (1.3-3.0) 3.6c (2.5-4.7)
Mood or anxiety disorder
All 11.2 (11.0-11.5) 4.7c (4.1-5.4) 3.1c (2.5-3.8) 5.5c (4.2-6.4)
Male 8.2 (8.0-8.6) 3.7c (2.9-4.6) 2.2c (1.5-3.2) 3.9c (2.3-5.5)
Female 14.1 (13.8-14.5) 5.7c (4.7-6.8) 3.8c (3.0-5.1) 7.1c (5.3-8.5)
aData were derived from the Ontario components ofStatistics Canada’s Canadian Community Health Surveys (CCHS).Using indirect standardization,
estimates were age- and sex-standardized (sex-specific estimates are age-standardized only) to the 2001 to 2014 Ontario CCHS populatio
12 to 14 followed by 5-year age categories and were weighted by the survey sample weight. Information on self-rated mental health and p
mood or anxiety disorders was collected from 2003 to 2014,and suicidalideation variables were collected from 2001 to 2008;allother variables were
collected from 2001 to 2014.
bBootstrap methods were used to derive 95% confidence intervals (CIs) for comparisons of estimates for nonwhite ethnic groups with estim
population.
cIndicates point estimate is significantly different from the corresponding estimate for the white population,with P < .05.
La Revue Canadienne de Psychiatrie 63(7) 485

service use, which remained consistent even after controlling
for severalfactors.However,Chinese respondents had the
poorestself-rated mentalhealth and the weakestsense of
belonging. Unmet needs for care were high across all 4 ethnic
groups, with more than half not seeking help despite reporting
mentalhealth issues.This was even higher among ethnic
minorities, particularly those of Chinese descent. The ethnic
differences found in this study may be a result of differences
in mental illness reporting, help-seeking behaviours, or access
to health services or may reflecttrue differences in mental
health burden across ethnic groups.
We found a lower prevalence of diagnosed mood and anxi-
ety disorders and lifetime suicidal ideation among South Asian,
Chinese, and black respondents compared to white individuals,
which is consistentwith previous Canadian and US-based
studies.3-5,28-32
However,Chinese respondents were unique
in that, despite a lower prevalence of the aforementioned ill-
nesses and factors, they had the weakest sense of belonging
poorest self-rated mental health, the lowest use of mental he
services, and the highest level of unmet needs. It is difficult t
explain these differences among Chinese individuals, but par
of this may be due to traditional beliefs about mental health.
many Chinese cultures, mental illness is believed to be cause
by lack of harmony of emotions or by evil spirits, resulting in
the seeking of more nontraditional or non-Western methods o
treatment.33 Indeed,our study found that among those who
sought mental health treatment, Chinese respondents were t
only group to have a significantly higher prevalence of menta
health care visits to other or alternative health professionals
compared to white individuals (14% vs. 6.0%, respectively).
Table 3. Age- and Sex-Standardized Prevalence ofMentalHealth and Addictions Factors,by Ethnic Group and by Immigrant Status,
Ontario,Canada,2001 to 2014.a
White
(n ¼ 238,392)
South Asian
(n ¼ 6779)
Chinese
(n ¼ 5073)
Black
(n ¼ 4707)
Immigrant status,n
Immigrant 33,895 5591 4001 3264
Canadian born 204,034 1127 1025 1358
Missing 463 61 47 85
% (95% CIb) % (95% CIb) % (95% CIb) % (95% CIb)
Somewhat weak/weak sense of belonging
Immigrant 37.5 (36.5-38.5) 28.1c (26.4-29.8) 50.8c (48.0-52.8) 35.0c (32.3-37.4)
Canadian born 32.9 (32.5-33.3) 29.4c (26.0-33.0) 42.6c (39.0-46.5) 36.5c (33.1-40.2)
Fair/poor self-rated mentalhealth
Immigrant 4.9 (4.5-5.4) 5.4 (4.4-6.3) 8.2c (6.9-9.6) 4.8 (3.6-6.0)
Canadian born 5.7 (5.5-5.9) 4.5 (2.9-6.7) 4.5 (2.5-6.2) 5.7 (4.1-7.6)
Lifetime suicidalideation
Immigrant 6.3 (5.6-6.9) 3.5c (2.4-4.7) 4.5c (3.4-5.9) 2.5c (1.8-3.6)
Canadian born 9.1 (8.8-9.4) 5.0c (3.1-7.7) 5.3c (2.7-8.4) 7.7 (4.9-10.5)
Mood or anxiety disorder
Immigrant 9.0 (8.4-9.6) 5.1c (4.3-5.9) 3.2c (2.5-4.0) 5.8c (4.2-7.1)
Canadian born 11.4 (11.3-11.8) 5.8c (3.6-8.3) 3.6c (2.3-5.4) 6.1c (4.6-8.2)
Any past-year mentalhealth visit
Immigrant 8.5 (8.0-9.0) 5.1c (4.4-5.8) 2.6c (2.0-3.3) 5.3c (4.3-6.3)
Canadian born 11.6 (11.4-11.9) 6.9c (4.7-9.1) 5.9c (3.5-8.6) 9.5c (7.8-11.4)
Among those with any past-year mentalhealth
visit-proportion by type of health professional
Family doctor
Immigrant 58.4 (55.4-61.1) 59.6 (53.1-66.7) 44.2c (32.9-56.7) 52.1 (41.5-61.4)
Canadian born 55.5 (54.4-56.6) 69.7c (50.5-81.6) 27.5c (14.4-47.2) 52.1 (40.7-64.2)
Psychiatrist
Immigrant 22.4 (20.2-25.1) 23.5 (17.5-30.3) 28.8 (19.3-40.1) 26.3 (16.7-35.2)
Canadian born 20.9 (20.0-21.8) 18.5 (7.7-31.0) 14.2 (2.9-28.9) 21.0 (11.4-29.5)
Allied health
Immigrant 31.1 (27.7-33.7) 27.2 (21.3-32.9) 28.5 (19.2-39.0) 40.1c (29.7-50.5)
Canadian born 37.7 (36.8-38.8) 30.8 (21.4-44.1) 48.5 (26.8-70.1) 42.4 (33.0-51.1)
aData were derived from the Ontario components ofStatistics Canada’s Canadian Community Health Surveys (CCHS).Using indirect standardization,
estimates were age- and sex-standardized to the 2001 to 2014 Ontario CCHS population using age groups 12 to 14 followed by 5-year age ca
were weighted by the survey sample weight. Information on self-rated mental health and physician-diagnosed mood or anxiety disorders was
2003 to 2014,and suicidalideation variables were collected from 2001 to 2008;allother variables were collected from 2001 to 2014.
bBootstrap methods were used to derive 95% confidence intervals (CIs) for comparisons of estimates for nonwhite ethnic groups with estimate
population.
cIndicates point estimate is significantly different from the corresponding estimate for the white population,with P < 0.05.
486 The Canadian Journalof Psychiatry 63(7)

Sense of belonging is associated with positive well-being and
mental health and lower rates of depression.13,14
Black individ-
uals reported a similar sense of belonging as white individuals,
while South Asians reported the strongest sense of belonging
across all ethnic groups. South Asians represent the largest visi-
ble minority population in Ontario, and as noted in a 2010 study,
a high proportion of the South Asian population lives in ethnic
enclaves.34This may have contributed to our finding of a lower
prevalence of fair or poor self-rated mental health among South
Asians as studies of populations in Europe have shown that
psychopathology is lower among immigrants and ethnic mino-
rities who live in areas that have a higher proportion of residents
of their own racial background.35,36
Although ethnic enclaves
were not reported to be common among the black population in
the study by Qadeer et al.,34 past literature has reported that
living in more racially diverse neighbourhoods was associated
with a stronger sense of belonging to Canada.37Thus, the racial
diversity of Ontario may help explain the positive self-rated
mental health reported by black individuals in our study.
Similar to South Asians, a large proportion of the Chinese
population in Ontario lives in ethnic enclaves.However,our
study,along with previous evidence,has found that Chinese
individuals had a weak sense of belonging and poor self-rated
mental health,12,28
suggesting that living in an ethnic enclave
does not provide the same protection towards positive mental
health across all ethnic groups. Indeed, Wu et al.37noted that
among those living in more racially diverse communities,
Asians reported a stronger sense of belonging towards the
ethnic group (in-group belonging) but a weaker sense of b
ing to Canada as a whole. This same study found that the
site was true for white individuals living in racially diverse
(i.e., they reported a stronger sense of belonging to Canad
weaker sense of in-group belonging).37In our study, we found
that 1 in 3 white individuals reported a weak sense of belo
despite being the majority ethnic group. The reasons for th
unclear, and further work is needed to explore the associa
between racial diversity and sense of belonging and how t
association might vary across ethnic groups.
The lower use of mentalhealth services among ethnic
minorities found in our study and supported by previous lit
erature3,8,9,38
may reflect a reluctance to seek help. For exam
ple, we found that even among those in need of mental he
care,unmet needs—while high across all ethnic groups—
were even higher among ethnic minorities.Few previous
Canadian studies reported similar findings,with Chen
et al.20noting high unmet needs among Chinese immigrants
in British Columbia, while another study reported that indi-
viduals of black, Japanese, Chinese, Korean, and South Asi
descent who had major depressive episode were all signifi
cantly less likely to seek treatment compared to white indi
viduals.21 Studies in the United States have also similarly
reported higher unmetneeds in both black and Asian
Table 4. Age- and Sex-Standardized Prevalence of MentalHealth Service Utilization,by Ethnic Group,Ontario,Canada,2001 to 2014.a
White (n ¼ 238,392)South Asian (n ¼ 6779)Chinese (n ¼ 5073)Black (n ¼ 4707)
% (95% CIb) % (95% CIb) % (95% CIb) % (95% CIb)
Any past-year mentalhealth visit
All 11.3 (11.0-11.5) 5.1c (4.5-5.9) 3.0c (2.4-3.7) 6.2c (5.3-7.1)
Male 7.3 (7.1-7.6) 3.1c (2.4-3.8) 1.8c (1.2-2.7) 3.9c (2.7-5.0)
Female 15.0 (14.7-15.3) 7.1c (6.0-8.4) 4.0c (3.1-5.2) 8.4c (6.9-10.0)
Mentalhealth visit by type of health professional
Family doctor 6.3 (6.1-6.5) 3.1c (2.5-3.8) 1.1c (0.8-1.5) 3.1c (2.4-3.9)
Psychiatrist 2.4 (2.3-2.5) 1.1c (0.8-1.4) 0.7c (0.5-1.0) 1.4c (1.0-2.0)
Allied health 4.1 (4.0-4.3) 1.5c (1.2-1.8) 1.1c (0.7-1.5) 2.7c (2.1-3.4)
Other 0.7 (0.6-0.7) 0.3c (0.1-0.4) 0.4c (0.2-0.7) 0.3c (0.2-0.5)
Among those with any past-year mentalhealth
visit,proportion by type of health professional
Family doctor 56.1 (55.1-57.2) 60.0 (53.4-66.0) 37.8c (29.1-48.4) 49.8 (42.4-57.8)
Psychiatrist 21.1 (20.3-22.0) 21.7 (16.7-27.9) 25.0 (17.6-33.9)23.3 (16.3-30.1)
Allied health 36.5 (35.6-37.6) 29.3c (23.5-35.0) 36.9 (27.4-47.4)44.3c (35.4-51.4)
Other 6.0 (5.6-6.6) 5.4 (2.5-8.2) 14.0c (6.2-22.0) 5.4 (2.5-8.6)
Among those with fair/poor self-rated mental
health, proportion with past-year mental health
visits
50.8 (49.2-52.2) 35.8c (29.3-44.0) 13.7c (8.9-19.0) 38.3c (29.8-46.5)
Among those with past-year suicidalideation,
proportion with past-year mentalhealth visits
53.2 (49.8-57.0) 51.4 (21.1-76.4) 19.9c (5.6-38.1) 43.6 (18.8-66.1)
aData were derived from the Ontario components ofStatistics Canada’s Canadian Community Health Surveys (CCHS).Using indirect standardization,
estimates were age- and sex-standardized (sex-specific estimates are age-standardized only) to the 2001 to 2014 Ontario CCHS populatio
12 to 14 followed by 5-year age categories and were weighted by the survey sample weight.
bBootstrap methods were used to derive 95% confidence intervals (CIs) for comparisons of estimates for nonwhite ethnic groups with estim
population.
cIndicates point estimate is significantly different from the corresponding estimate for the white population,with P < 0.05.
La Revue Canadienne de Psychiatrie 63(7) 487

populations.17,18Reluctance to seek help may be due to
increased shame and stigma among ethnic minorities. Bar-
riers to mental health service use that have been noted in the
literature include individualand family factors,such as
shame and stigma, as well as system-level factors, such as lack
of culturally sensitive mental health services or institutional
racism.39-41
Previous studies have indicated that Chinese and
South Asian patients present to hospital with far more severe
psychiatric symptoms, indicating a delay in seeking help, while
other studies suggest that among black patients, multiple hos-
pitalizations and involuntary admissions result in distrust with
the mental health system.42,43
A major strength of this study was the population-based
sample and the use of survey weights,which allowed for
greater generalizability.We had a large sample of over
16,000 ethnic minorities, which enabled us to not only compa
across these major ethnic groups living in the same macro-
environment but also examine the effects of age and immigr
tion within each ethnic group.Although paststudies have
assessed a limited number of mental health–related factors
among single ethnic groups or immigrants of various ethnici-
ties and have largely been unable to disaggregate Chinese fr
South Asians, the present study was able to assess a list of k
mental health factors simultaneously and across the Canada’
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0
Past year mental
health service use
South Asian
Chinese
Black
OR=0.43 (0.37, 0.51)
OR=0.42 (0.36, 0.49)
OR=0.54 (0.46, 0.63)
OR=0.26 (0.21, 0.33)
OR=0.25 (0.20, 0.31)
OR=0.32 (0.25, 0.41)
OR=0.56 (0.47, 0.67)
OR=0.52 (0.43, 0.62)
OR=0.54 (0.45, 0.65)
Odds rao (95% CI)
Crude
Age-sex
Mulvariate
Diagnosed mood or
anxiety disorder
South Asian
Chinese
Black
Fair or poor self-rated
mental health
South Asian
Chinese
Black
OR=0.36 (0.31, 0.43)
OR=0.37 (0.32, 0.43)
OR=0.44 (0.37, 0.52)
OR=0.25 (0.20, 0.32)
OR=0.25 (0.20, 0.31)
OR=0.30 (0.23, 0.38)
OR=0.46 (0.36, 0.59)
OR=0.45 (0.35, 0.58)
OR=0.43 (0.34, 0.56)
OR=0.81 (0.67, 0.98)
OR=0.85 (0.70, 1.02)
OR=0.89 (0.71, 1.11)
OR=1.27 (1.06, 1.52)
OR=1.30 (1.08, 1.56)
OR=1.41 (1.16, 1.72)
OR=0.76 (0.61, 0.94)
OR=0.78 (0.63, 0.97)
OR=0.66 (0.53, 0.83)
Figure 1. Forest plot of crude and multivariate-adjusted odds ratios (ORs) of the association between ethnicity and mental he
service utilization, Ontario, Canada, 2001 to 2014. Data were derived from the Ontario components of Statistics Canada’s Ca
Health Surveys (CCHS). Bootstrap methods were used to derive 95% confidence intervals. Multivariate ORs were adjusted fo
education, immigrant status, and CCHS cycle/survey year. Odds ratios (OR) for South Asian, Chinese, and Black individuals a
White reference population. ORs were considered to be statistically significant when confidence intervals did not overlap wit
488 The Canadian Journalof Psychiatry 63(7)

major ethnic groups. Another strength of the study was that the
CCHS survey was conducted in over 25 languages, which is
especially important given the ethnic and immigrant focus of
this study. In addition, we were able to examine the types of
mentalhealth services individuals soughtmore broadly,
including those provided by psychologists, social workers, and
other allied health professionals that are not currently captured
in provincial administrative health data.
Limitations
The present study is not without limitations.First,this study
relied on self-reported data and may be influenced by cultural
differences in reporting or perceptions around mental health.
Self-report, however, may be the best method to assess certain
mental health factors, such as self-rated mental health, sense of
belonging,and suicidal ideation,which cannot be measured
using administrative or clinical databases and do not rely on an
individual making contact with the health care system. Second,
due to limitations with the questions asked in the CCHS, we were
unable to disentangle whether the observed ethnic differences in
self-reported diagnosed mental health conditions were the result
of differences in reporting, help-seeking behaviours, or access to
health services or reflected true differences in mental health
burden.Third,this study combined multiple survey waves to
acquire a large sample of ethnic minorities and therefore may
have masked temporal trends in mental health status.Last,
results were restricted to Ontario only, which may not necessa-
rily be generalizable to less racially diverse regions in Canada.
Conclusion
In this large,population-based study,our results highlight
the importance ofethnic-specific analysis as we found
marked ethnic variations in self-reported mental health fac-
tors, service utilization, and unmet needs. The considerably
lower use of mental health services among ethnic minorities
with poor mental health is cause for concern. Further work is
needed to better understand and address cultural and system-
level barriers surrounding high unmet needs and to identify
ethnically tailored and culturally appropriate clinicalsup-
ports and practices to ensure equitable and timely mental
health care.Moreover,as funding towards mentalhealth
services increases in Ontario,our results provide baseline
estimates that can be compared to future estimates to ensure
that any improvements to mental health care provisions and
outcomes are equitably shared across all ethnic groups.
Acknowledgments
This study was supported by the Institute for Clinical Evaluative
Sciences (ICES), which is funded by an annual grant from the Ontario
Ministry of Health and Long-Term Care (MOHLTC). All decisions
regarding study design,publication,and data analysis were made
independentof the funding or sponsoring agencies.The authors
acknowledge that the data used in this publication are from Statistics
Canada’s Canadian Community Health Survey (CCHS). We thank
all the participants of the CCHS and the staff from Statistics Cana
who assisted in the survey data collection and management. We
acknowledge the Mental Health and Addictions Scorecard and Ev
luation Framework grant from the Ontario MOHLTC.
Author Contributions
M. Chiu was the principal investigator, conceived the study, and
pared the first draft of the manuscript. A. Amartey performed the
ature review. X. Wang performed the statistical analyses. All aut
interpreted the data,critically revised the manuscript for important
intellectual content, and approved the final version of the manus
X. Wang had full access to all the data in the study and takes res
sibility for the integrity of the data and the accuracy of the data
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with resp
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
research, authorship, and/or publication of this article: The Instit
Clinical Evaluative Sciences (ICES) is funded by the Ontario
MOHLTC. The study results and conclusions are those of the auth
and should not be attributed to any of the funding agencies or sp
agencies. No endorsement by ICES or the Ontario MOHLTC is inte
or should be inferred. All decisions regarding study design, publi
and data analysis were made independent of the funding agenci
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490 The Canadian Journalof Psychiatry 63(7)

Appendix Table 1. Sex-Standardized Prevalence of Mental Health and Addictions Factors, by Ethnic Group and by Age, On
2001 to 2014.a
White
(n ¼ 238,392)
South Asian
(n ¼ 6779)
Chinese
(n ¼ 5073)
Black
(n ¼ 4707)
Age group,n
12-24 38,644 1768 1264 1244
25-64 137,487 4350 3226 2946
65þ 62,261 661 583 517
% (95% CIb) % (95% CIb) % (95% CIb) % (95% CIb)
Somewhat weak/weak sense of belonging
12-24 32.5 (31.8-33.2)25.3c (22.6-28.3) 44.0c (40.5-47.4) 36.2c (31.9-39.7)
25-64 35.4 (35.0-35.9)30.3c (28.1-32.2) 52.9c (49.7-55.3) 37.1 (34.3-39.9)
65þ 26.6 (26.1-27.2) 31.1 (25.2-36.2)52.2c (45.2-58.7) 21.4c (17.0-25.7)
Fair/poor self-rated mentalhealth
12-24 4.4 (4.0-4.7) 4.2 (2.8-5.8) 4.6 (2.9-6.5) 3.9 (2.7-5.4)
25-64 6.2 (6.0-6.5) 4.5c (3.7-5.5) 7.9c (6.4-9.6) 4.7c (3.5-5.9)
65þ 5.1 (4.8-5.4) 7.6c (4.8-10.7) 11.0c (7.0-15.0) 5.8 (3.7-8.6)
Lifetime suicidalideation
12-24 9.4 (8.7-10.2) 4.0c (2.1-6.0) 5.4c (3.0-8.2) 5.6c (3.4-8.3)
25-64 9.4 (9.0-9.7) d d d
65þ 4.2 (3.9-4.6) d d d
Mood or anxiety disorder
12-24 9.2 (8.7-9.6) 3.9c (2.6-5.4) 2.5c (1.7-3.6) 3.6c (2.5-5.0)
25-64 12.6 (12.3-13.0) 4.8c (4.0-5.6) 3.0c (2.2-3.9) 6.3c (4.5-7.6)
65þ 8.7 (8.4-9.1) 6.8c (4.8-9.1) 4.3c (2.1-6.8) 4.4c (2.0-6.9)
Any past-year mentalhealth visit
12-24 9.2 (8.7-9.6) 4.2c (2.9-5.6) 3.3c (2.2-4.6) 4.8c (3.7-6.4)
25-64 13.2 (12.9-13.5) 5.9c (5.0-6.9) 3.2c (2.4-4.1) 7.4c (6.1-8.8)
65þ 5.4 (5.1-5.6) 4.1 (2.5-5.9) 1.8c (0.5-3.8) 2.4c (1.1-3.9)
Among those with any past-year mentalhealth visit,
proportion by type of health professional
Family doctor
12-24 46.0 (43.6-48.2) 54.1 (38.5-69.0) 40.0 (25.3-62.0) 49.2 (34.7-61.2)
25-64 57.7 (56.4-58.8) 60.5 (53.0-68.3)36.8c (25.9-49.1) 48.3 (39.8-57.9)
65þ 63.8 (61.1-66.2) 68.5 (48.2-89.3) 33.1 (4.5-94.9) 67.4 (40.6-96.2)
Psychiatrist
12-24 20.0 (18.1-22.2) 23.4 (11.5-39.0) 14.0 (2.1-28.5) 18.4 (7.4-28.4)
25-64 21.4 (20.4-22.3) 20.3 (14.6-27.0) d d
65þ 21.6 (19.3-24.0) 23.2 (6.5-44.0) d d
Allied health
12-24 50.7 (48.5-53.4) 46.9 (31.3-63.8) 38.7 (22.3-60.2) 46.5 (33.9-62.2)
25-64 34.9 (33.8-36.2) d 40.7 (27.0-54.0) d
65þ 19.6 (17.7-21.5) d 0.0 (0.0-0.0) d
aData were derived from the Ontario components of Statistics Canada’s Canadian Community Health Surveys. Using indirect standardizatio
sex-standardized to the 2001 to 2014 Ontario CCHS population using age groups 12 to 14 followed by 5-year age categories and were wei
sample weight.Information on self-rated mentalhealth and physician-diagnosed mood or anxiety disorders was collected from 2003 to 2014,and suicidal
ideation variables were collected from 2001 to 2008;allother variables were collected from 2001 to 2014.
bBootstrap methods were used to derive 95% confidence intervals (CIs) for comparisons of estimates for nonwhite ethnic groups with estim
population.
cIndicates point estimate is significantly different from the corresponding estimate for the white population,with P < 0.05.
dValue was suppressed to reduce risk of re-identification due to smallcells.
La Revue Canadienne de Psychiatrie 63(7) 491