Measuring the effect of a large reduction in welfare payments on mental health service use in welfare-dependent neighborhoods

Background: Major social policy changes were implemented in Canada in the last decade with few efforts to examine their potential health effects. Objectives: We sought to determine the impact of a large reduction in welfare benefits on use of ambulatory physician mental health services in areas with high levels of welfare dependency relative to areas with low levels of welfare dependency. Methods: The setting was Toronto, Canada. Data sources included census, provincial health insurance, and municipal welfare data. We used generalized estimating equations to compare ambulatory mental health service rates by neighborhood level of welfare dependency before and after a 21.6% reduction in welfare payments. Results: There were no long-term relative differences by welfare dependency in mental health service use before compared with after the policy change. There was a very small short-term increase in mental health visits to generalists in the 6 months after the policy change. We demonstrated a marked gradient in psychiatric service use with low welfare dependency areas having significantly higher rates of use than high welfare dependency areas. Conclusions: We demonstrated a mismatch between known levels of need for care and levels of psychiatric use. We conclude that where use of services is not tightly linked to need for services, utilization data may be unsuitable for evaluating programs or policies. Social policy changes with potential health effects should have integrated evaluations planned at the time of policy implementation.