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Profiles of physician follow-up care, correlates and outcomes among patients affected by an incident mental disorder

BMC Primary Care volume 26, Article number: 7 (2025) Cite this article

Abstract

Objectives

This study identified profiles of outpatient physician follow-up care and other practice features, mostly after detection of incident mental disorders (MD), and associated these profiles with patient characteristics and subsequent adverse outcomes.

Methods

A cohort of 170,957 patients age 12 + with a new or recurrent MD detected in 2019-20 was investigated based on data from the Quebec Integrated Chronic Disease Surveillance System. Latent class analysis was performed to identify follow-up care profiles, mostly within one year of MD detection. Bivariate analyses tested associations between profiles and patient characteristics; logistic regressions examined relationships between profiles and adverse outcomes after one year.

Results

Five profiles were identified: Profiles 2 and 5 (64%) offered low mental health (MH) outpatient follow-up care, while the others dispensed higher MH follow-up care. Profiles differed in patient characteristics and related outcomes. Labelled “Follow-up care by usual psychiatrist”, Profile 1 (1% of sample) included younger patients with the most health and social issues. Profile 2 (50%), “Low MH follow-up care but high prior consultations for physical reasons”, mostly integrated older patients with chronic physical illnesses. Profile 3 (11%), “Follow-up care by general practitioners (GP) and psychiatrists”, referred to physicians other than the usual ones (e.g., walk-in practice) and encompassed patients with severe MD conditions. Profile 4 (23%), “High follow-up care by usual GP and prior consultations for physical reasons”, showed the typical characteristics of patients treated in primary care (more common MD, women, less materially and socially deprived). Profile 5 (15%), “Low MH follow-up care and prior consultations for physical reasons”, integrated more younger men, materially deprived patients, and with substance-related disorders (SRD) or co-occurring MD-SRD. More Profile 1 and 3 patients lived in university regions – those of Profile 4 were the least numerous in such regions. More Profile 5 patients lived in metropolitan and rural areas. Risk of death was higher in Profiles 5, 2, 3, and risk of frequent ED use and hospitalization higher in Profiles 1, 3, and 5 – patients with severe health and social issues.

Conclusion

The study confirmed the need to improve prompt, adequate and continuous follow-up care for patients with incident MD.

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Introduction

Receiving prompt, adequate, and continuous physician follow-up care after detection of an incident mental disorder (MD), including substance-related disorders (SRD), is crucial for patient recovery [1] and a key trend in system reforms [2, 3]. An “incident MD” is a new or recurrent MD episode, detected after a three-year clearance period without a MD diagnosis. Prompt medical care may be defined as at least receiving one follow-up care by a physician in the 4 weeks following incident MD detection [4,5,6] – a strong benchmark for best practices, here as in acute care (emergency department (ED) use and hospitalization) [7,8,9,10]. For follow-up care to be adequate, at least 3 interventions may be required within the following 90 days [10,11,12,13] – the proper amount of time for acute MD to be stabilized [11, 14]. Continuous follow-up care may include at least 5 consultations/year to achieve patient recovery [6, 10, 15, 16]. Follow-up care might prevent adverse outcomes like frequent ED use [1, 17], psychiatric readmission [5, 18], and death [19]. The few studies that have measured comparable quality of care indicators found that only about half of patients receive the appropriate amount of follow-up care after MD detection [4, 6, 10, 20, 21].

Follow-up practices may vary according to the seniority or type of physicians providing the care: general practitioners (GP) or psychiatrists; physicians in long-term facilities or family medicine group settings with teamwork practices; “usual” GP – a proxy for family doctor – or any GP in walk-in clinics [22,23,24,25]. Junior and senior physicians could have different practices, with some working more extensively in walk-in clinics, delivering more patient follow-up care, or handling more complex or new cases [26]. Prior continuity or intensity of care may influence quality of care after MD detection. A patient’s sociodemographic and clinical characteristics may also indicate whether they will receive follow-up care or seek help. Youth and patients with SRD are especially known to have less access to care and to use less services than the adult population or patients with MD [4, 27, 28]. Conversely, women, older patients, and patients with more serious MD (e.g., psychotic disorders) are known to use more services and have greater access to care [29,30,31]. A better understanding of physician follow-up care profiles after detection of incident MD, with integration of diversified physician practice features associated with patient characteristics, may help stakeholders recommend service improvements for these vulnerable and heterogeneous populations. Using person-centered approaches, which correlate specific respondent traits rather than variables linked to heterogeneous populations or subgroups, may offer effective solutions for identifying distinct physician follow-up care profiles [32].

While several studies investigate patient service use profiles [10, 13, 25, 33,34,35], few examine physician follow-up care profiles among patients with incident MD. While a limited number of studies have linked such profiles to patient outcomes [33], correlates of best treatment practices [13, 36,37,38] have been studied more extensively. One study found five GP practice profiles: three provided important care for patients with MD in GP group practices, but the other two (36% of all GP) integrated GP working in diversified practices with low volume of patients, or in high volume walk-in clinics who didn’t take on many patients with MD [25]. Another five-profile study [39] considered the quality of care in the 12 months following an ED visit for incident MD. Nearly 40% of these patients, especially those with SRD, received virtually no medical follow-up care after ED discharge, and roughly half received care exclusively from their usual GP [39]. Outcomes were poorer in profiles of patients who received less care, and better in those with more intensive GP care [39]. Another study, identifying four profiles of patients with schizophrenia using primary care over a 3-year period, showed that profiles with increased or consistent primary care had lower risks of death [33]. Overall, women, patients with more severe health conditions, materially or socially deprived or older individuals received more best-practice treatments [4, 13, 28], and follow-up care provided in teamwork practice ranked better in study evaluations on mental health (MH) outcomes [20, 40].

To our knowledge, no prior study has identified profiles of prompt, adequate and continuous physician MH follow-up care after the detection of an incident MD, while integrating other physician practice features, including previous GP care for physical reasons. This study is also innovative in that it tested associations between follow-up care profiles and patient characteristics, then linked those profiles to adverse outcomes. For instance, younger patients might be treated more by psychiatrists only, while those in family medicine groups might be older and receive more GP care. Patients could be treated adequately by GP for their physical care prior to the detection of their MD, yet receive no follow-up though them once their new MD is diagnosed. Assessing the quality of follow-up care received among patients with serious MD, common MD, or SRD may hint at how the MH system responds to the needs of these patients – an important issue, as patients who receive more follow-up care after MD detection tend to have less adverse outcomes such as frequent ED visits, hospitalization, and death. Based on the Quebec Integrated Chronic Disease Surveillance System (QICDSS), this study aimed to identify profiles of physician follow-up care and other physician practice features, and to associate these profiles with patient characteristics and subsequent adverse outcomes among Quebec patients diagnosed with incident MD in the fiscal year 2019-20.

Methods

Study design, data sources, sample

This observational epidemiologic study is based on an original 25-year cohort (fiscal year April 1, 1997 to March 31, 2022) of more than 2.5 million patients age 12 and over who had received an incident MD diagnosis, using data from the QICDSS, which integrates the medical administrative data of 98% of the Quebec population [41] – details on this cohort were presented in another publication [10]. In this larger previous cohort, if an individual had several incident MD episodes during this 25-year period (e.g., in 2002, 2008 and 2019), only the last incident MD (i.e., 2019) was included [10]. In the present study, only patients who had a last incident MD (including SRD) diagnosed between April 1, 2019 and March 31, 2020 were included. Data for this QICDSS cohort were taken from the province Health Insurance Registry (FIPA, e.g., age, sex), the Physician Claims Database (RAMQ), the Hospital Inpatient Database (MED-ECHO), and the Death Database (RED). In Quebec (Canada), health services are mostly public, covering medical and some psychosocial services (e.g., social workers and psychologists from community health care centers) [3, 42]. The QICDSS integrated physician care only, either as outpatient or acute care, with the patients’ treatments mainly being decided by the physicians and GP providing most of the MH care [43, 44]. If a variable appeared in several databases (e.g., diagnoses), data were merged (see Table 1 footnotes). Diagnostic codes (RAMQ, MED-ECHO) for MD or SRD, physical illnesses, suicide attempts, homelessness, and cause of death were based on the International Classification of Diseases, Ninth or Tenth Revisions (Appendix 1).

Table 1 Characteristics of patients with incident mental disorders from April 1, 2019 to March 31, 2020 (N = 170,957, or other as specified)
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“Incident MD” was defined as requiring two MD diagnoses in the RAMQ, or a primary MD diagnosis in MED-ECHO [45] – except for SRD, which required only one diagnosis as they are often underdiagnosed [46]. The 3-year clearance period without MD required to be considered as having an incident MD is consistent with the notion of recovery from MD-SRD [47,48,49], and controlled for prior MD episodes in the longitudinal database. The initial cohort for the fiscal year 2019-20 included 176,682 patients, but those who died during the one-year MH follow-up care period or were hospitalized for more than a third of it (≥ 4 months) were excluded, as these conditions hinder the measurement of outpatient MH follow-up care – the main study variable after detection of incident MD. The study followed the Strobe guideline for epidemiological studies [50], and was approved by the research ethics committee of the Douglas Mental Health University Institute.

Study variables

The following variables were used in the analysis of physician outpatient follow-up care profiles measured for the fiscal year 2019-20 after MD detection: receiving (a) prompt (at least 1 consultation within 30 days) [4,5,6], (b) adequate (at least 3 consultations within 90 days) [11,12,13], or (c) continuous (at least 5 consultations within 365 days) MH follow-up care by the patient’s “usual psychiatrist” or “ usual GP”, or “other GP and psychiatrists” [6, 15, 16]; and (d) receiving physician psychotherapy (within these 12 months). (e) The physician’s seniority in the profession (≥ 20 years) was also integrated in the follow-up care profiles, but measured from 1997 to 2020. The other variables encompassed in the outpatient follow-up care profiles were measured for the 2 years before MD detection, and thus concerned care for physical reasons only: (f) prior consultations with GP; (g) prior care provided in family medicine groups or (h) in long-term facilities; and (i) prior high continuity of GP care. The “usual psychiatrist” designation required at least 2 consultations with the same psychiatrist during the one-year MH follow-up care period, after detection of the patient’s incident MD. The “usual GP” designation required at least 2 consultations for any reason with the same GP in a 3-year period (i.e., the 2 years prior to MD detection and the one-year period after MD detection). “Usual GP” is a proxy for “family doctor”, physicians who should assume “long-term overall care” for their patients – though this data is not available in administrative databases. However, as all patients had incident MD in 2019-20, with a 3-year previous clearance period without MD, prior GP care in the 2-year period before MD detection couldn’t include MH care. Prompt, adequate or continuous MH follow-up care after MD detection distinguished if MH care was provided either by the “usual psychiatrist”, “usual GP” (or family doctor), or “GP and psychiatrists other than the usual ones”. “Other GP and psychiatrists” (other than the usual ones) designates notably those working in walk-in clinics or administering brief intervention (i.e., 1–4 short counselling sessions [51]) in specialized care [52, 53], neither of which usually provide patient follow-up. The “seniority in the profession” variable considered the usual principal physician who provided MH follow-up care – most often the usual GP; when there were no usual physician, the mean seniority of the other physicians who administer MH follow-up care would be provided. The 20-year benchmark for physician seniority was based on a 50% distribution of their seniority in the database – the physician workforce is known to have aged significantly in Canada in recent years [54], with a mean of about 49 years old [55]. Family medicine groups are medical clinics with patient registration that include GP group practice and psychosocial clinicians (e.g., nurses, social workers) who deliver extended medical coverage [56]. Physicians may also deliver follow-up care in long-term facilities including nursing homes, and youth or detention centers. Continuity of GP care was measured with the Usual Provider Continuity Index [57], which describes the proportion of consultations with the “usual GP” out of all GP consulted in outpatient care (e.g., walk-in clinics) – a score of ≥ 0.67 indicates high care continuity [58].

Sociodemographic correlates included: (a) sex at birth, (b) age group, (c) material and (d) social deprivation, (e) type of healthcare region (e.g., university) and (f) residential area (e.g., rural) measured at MD detection in 2019-20, and (g) being homeless – measured within the two years before MD detection. Based on the smallest geographic areas of the 2016 Canadian census, the Material and Social Deprivation Indexes were merged into two groups: least to moderately deprived areas (quintiles 1–3), and more deprived areas (quintiles 4–5). The Material Deprivation Index measured the proportion of population employment, average income, and number of individuals without a high school diploma, while the Social Deprivation Index measured the proportion of individuals living alone or without a spouse, and of single-parent families [59].

Clinical correlates included: (a) incident principal MD measured in 2019-20; b) number of prior MD episodes measured from April 1, 1997 to the date of the incident MD in 2019-20; (c) severity of chronic physical illnesses measured within 5 years before and during the 2019-20 incident MD; d) suicide attempts measured from April 1, 1997 to the 2019-20 incident MD; and (e) co-occurring MD-SRD or (f) MD-SRD-chronic physical illnesses measured over the 2019-20 period. Incident principal MD were classified hierarchically in this order: serious MD (schizophrenia spectrum and other psychotic disorders, bipolar disorders); personality disorder; common MD (depressive, anxiety, adjustment disorders; attention deficit/hyperactivity disorders); and SRD without MD (alcohol or drug use, induced disorders, intoxication, or withdrawal). For example, if a patient was diagnosed with a depressive disorder on April 1, 2019, they shouldn’t have received any MD diagnosis between April 1, 2016 and March 31, 2019 for it to be considered an “incident MD”. The number of prior MD episodes enabled to identify MD chronicity presenting more severe symptoms and implying extended treatments [60, 61]. For example, if a patient got a MD diagnosis in 2000-01 and another one in 2009-10 (including the 3-year clearance period for the detection of an incident MD), it was considered that this patient had 2 prior MD episodes before his or her incident MD in 2019-20. Chronic physical illnesses (e.g., cardiovascular illnesses) were assigned a 0–3+ severity score adapted from the Elixhauser and Charlson Comorbidity Indexes [62].

Adverse outcomes were measured 12 months after the end of the MH follow-up care period. For instance, for a patient who received an incident MD on April 1, 2019, the MH follow-up care period would ultimately end in March 31, 2020 (continuous follow-up care); therefore, the outcomes would be measured from April 1, 2000 to March 31, 2021. Adverse outcomes included: (a) frequent ED use (at least 4 visits/year) for any reason – a standard benchmark for frequent ED use [63, 64]; (b) hospitalization for MH reasons; (c) death by any cause, including accidental/intentional causes and physical causes. Those are key indicators for measuring adverse outcomes based on health administrative databases [65,66,67].

Data analysis

Latent class analysis (LCA) was performed to identify physician follow-up care profiles based on outpatient service use before (e.g., prior high continuity of GP care within 2 years for physical reasons) and after the last incident MD (e.g., prompt MH follow-up care) [68, 69]. Compared to standard cluster analysis with an arbitrarily chosen distance measure, LCA is a model-based technique that identifies population heterogeneity by analyzing individual behavioral patterns so profiles can be formulated [70]. Increasingly complex models (gradual addition of profiles) were estimated to determine the optimal number of latent classes, based on a patient’s highest probability of profile membership. Following standard practice, the Bayesian Information Criteria (BIC) [71] and Entropy Value [72] were used for selecting the final analytical classification model.

Bivariate analyses were computed to compare associations between sociodemographic correlates, clinical correlates, and profile membership. Chi-squared test adjusted with the Holm-Bonferroni method were used [73]. Relationships between profile membership and adverse outcomes (i.e., frequent ED use, hospitalization, death) were measured using logistic regressions, adjusted for age and sex. Multinominal regressions were not used as no single profile was judged distinctive enough to be compared with all other profiles. Analyses was performed using SAS 9.4 [74].

Results

Sample description

Of the 176,682 patients in the initial cohort, 5,669 (3.2%) died during the year of MH follow-up care considered, and 56 (0.03%) were hospitalized for more than a third of this period, taking into account the 3 MH follow-up care indicators (i.e., 10 days for prompt, 30 days for adequate, and 120 days for continuous MH follow-up care); those patients were removed from the study. In the final 170,957 cohort, 57% were women, 29% age 45–64, 41% were materially and 42% socially deprived patients, 36% lived in metropolitan areas, and 37% in university healthcare regions (Table 1). As incident principal MD, 72% had common MD, 19% serious MD, 10% co-occurring MD-SRD, 56% were at their first MD episode, and 13% had severe (3+) chronic physical illnesses. In total, over the two years before their incident MD and in their year of MH follow-up care, 83% of patients had a usual GP. In the one-year MH follow-up care period, 7% had a usual psychiatrist.

After MD detection, 32% received prompt, 32% adequate, and 42% continuous MH outpatient follow-up care; 5% got physician psychotherapy, and 75% were treated for their MD by physicians with ≥ 20 years seniority in the profession. In the two years prior to the incident MD detection, 82% had consulted a GP for their physical conditions, 72% were treated in family medicine groups, and 1% in long-term facilities; 39% had received a high continuity of GP care.

In the year following continuous follow-up care, 28% used ED, 3% were frequent ED users (accounting for 11% of all ED users), 5% were hospitalized for MH reasons, and 3% had died (see Table 4 for descriptive statistics on the outcomes).

Physician follow-up care profiles

The BIC decreased as class numbers increased. The five-class model was selected as it included a class with 1.3% (N = 2,243) of the sample, and the largest entropy value (> 0.9) (Appendix 2). This smallest class corresponded to Profile 1, which exhibited the most follow-up care by the usual psychiatrist, but almost no GP follow-up care for MH reasons (Table 2). After MD detection, almost all Profile 1 patients received continuous MH follow-up care (95%) and showed high percentages of prompt (66%) and adequate (81%) MH follow-up care, the second and third best MH follow-up care. Profile 1 also included the most patients (47%) receiving physician psychotherapy and living in long-term facilities (2%), and ranked second to last in patients registered in family medicine groups (69%) or in prior consultations with GP (71%) for physical reasons. Profile 1 was labelled “Follow-up care by usual psychiatrist”.

Table 2 Characteristics of the 5-class model based on service use – profiles of physician follow-up care (LCA*) (N = 170,957, or other as specified)
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Few Profile 2 patients (50% of sample) received physician MH follow-up care after MD detection: only 22% got continuous MH follow-up care, mostly from their usual GP (i.e., 18% with usual GP and 4% from other GP or psychiatrist, respectively); 11% received prompt MH follow-up care from the usual GP or other physicians; and only 2% received physician psychotherapy. However, in the two years before MD detection, Profile 2 showed the most patients with GP consultations for physical reasons (99%), and was second highest in continuity of GP care received for physical reasons (47%) and in family medicine group enrollment (80%). Profile 2 was labelled “Low MH follow-up care but high prior consultations for physical reasons”.

Profile 3 patients (11% of sample) mainly received prompt (76%), adequate (91%) and continuous (76%) MH follow-up care by GP and psychiatrists other than their usual physicians. While none of these patients received prompt or adequate MH follow-up care from their usual physician, 6% received continuous follow-up care from their usual GP and less than 1% from usual psychiatrist. Profile 3 ranked second in patients receiving physician psychotherapy (17%) and in care delivered in long-term facilities (1.5%). Profile 3 was labelled “Follow-up care by GP and psychiatrists”.

Patients in Profile 4 (23%) mainly received prompt (65%), adequate (92%) and continuous MH follow-up care (86%) from their usual GP. This profile included the most patients registered in family medicine groups (83%) and patients who previously received high continuity of GP care (61%) for physical reasons, and it ranked a close second in prior GP consultations for physical reasons (99.2%). Profile 4 was labelled “High MH follow-up care by usual GP and prior consultations for physical reasons”.

Profile 5 (15%) included very few patients who got MH follow-up care after MD detection: only 8% had received prompt and 7% continuous MH follow-up care from physicians other than their usual ones. But the physicians they consulted were the most senior (87% with ≥ 20 years of practice). Profile 5 included the lowest number of patients registered in family medicine groups (26%), and none of them showed consultations over the previous 2 years or high continuity of GP care for physical reasons. Profile 5 was labelled “Low MH follow-up care and prior consultations for physical reasons”.

Patient correlates

Profile 1 included the greatest number of young patients (24%: 12–17 years), followed closely by Profile 5 (Table 3). Profiles 1 and 3 included more patients who were socially deprived (48%) or living in university regions (41%). Profile 1 came first in homelessness (3%), patients with serious MD (60%), personality disorders (8%, like Profile 3), 2 + previous MD episodes (13%, like Profile 4), suicide attempts (7%), and co-occurring MD-SRD (17%, like Profile 5). Profile 2 had the most patients who were 65 + years old (24%), with severe chronic physical illnesses (17%) or co-occurring MD-SRD-chronic physical illnesses (6%). It came second in common MD (72%) or SRD (5%), and had the least patients with serious MD (18%). Profile 3 had the most 30–44 years old patients (32%), and was second highest in serious MD (26%) and suicidal behaviors (3%). Profile 4 included the most women (67%), patients who were 45–64 years old (35%), with common MD (74%); it also had the second highest number of patients 65 + years old (20%), but the least patients materially (40%) or socially (40%) deprived, living in university regions (36%, similar to Profile 5), with co-occurring MD-SRD (6%) or MD-SRD-chronic physical illnesses (4%). Profile 5 integrated the most men (58%), patients materially deprived (43%, like Profile 1), living in rural or metropolitan areas (20% and 37%, like Profile 4), and patients with SRD (8%). Profile 5 had the second highest percentage of patients age 12–17 (22%) or 18–29 (20%), and of homelessness (1%), but the least patients with 2 + prior MD episodes (10%).

Table 3 Percentages and comparisons of sociodemographic and clinical correlates between profiles of physician follow-up care (N = 170,957, or other as specified)
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Adverse outcomes

The risks of being a frequent ED user or of being hospitalized for MH reasons were significantly different in each profile for both outcomes (Table 4). Profile 1 exhibited the highest risks, followed by Profiles 3, 5, 4, and 2 (Fig. 1). The risk of death by any cause was highest in Profile 5, and higher in Profiles 2 and 3 than in Profiles 1 and 4.

Table 4 Characteristics and comparisons of adverse outcomes by profiles (N = 170,957)
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Fig. 1
figure 1

Comparisons of adverse outcomes between profiles (logistic regression adjusted by sex and age)1

*ED: emergency department (for any reason); MH: mental health

1: A model integrating all the study sociodemographic and clinical control variables was also tested. It reported very similar results than the model adjusted by sex and age only

Profile 1: “Follow-up care by usual psychiatrist”

Profile 2: “Low MH follow-up care but high prior consultations for physical reasons”

Profile 3: “Follow-up care by general practitioners (GP) and psychiatrists”

Profile 4: “High follow-up care by usual GP and high prior consultations for physical reasons”

Profile 5: “Low MH follow-up care and prior consultations for physical reasons”

The vertical blue line (at odds ratio = 1) is known as the “line of null effect”. An odds ratio on the right side of each blue line (OR > 1) is associated with higher odds of having the corresponding outcome. For example, when comparing frequent ED use between Profiles 1 and 2, we see that Profile 1 patients have a higher risk of being frequent ED users. An odds ratio on the left side of each blue line (OR < 1) is associated with lower odds of having the corresponding outcome. For example, when comparing frequent ED use between Profiles 2 and 3, we see that Profile 2 patients have a lower risk of being frequent ED users. If the 95% confidence interval (red bar) crosses 1 (the blue line), this implies there is no significant difference (e.g., Profile 1 vs. 4 physician follow-up care didn’t differ in inclusion of proportion of death for any cause)

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Discussion

This study identified profiles of MH follow-up care after incident MD detection, including other outpatient physician practice features and care in the two years prior for physical reasons, and associated these profiles with patient characteristics and subsequent adverse outcomes. Five profiles were identified: two profiles (2 and 5, 64% of sample) showed low MH follow-up care; patients in the other three experienced better MH follow-up care. Profiles differed substantially in terms of patient characteristics and related outcomes (Table 5).

Table 5 Summary of the 5 profiles of physician follow-up care and associated respondent characteristics and outcomes
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Profile 2 (50% of sample) included the most patients aged 65 + and with severe chronic physical illnesses. Prompt, adequate and continuous MH follow-up care were low, though 80% of these patients were integrated in family medicine groups and half had received prior high continuity of GP care for physical reasons (the second-best score for these indicators). These results of patients who receive high physical follow-up care but low MH follow-up care are typical, and so were not surprising considering GP are known to be reluctant to provide MH care or to lack MH expertise [75, 76]. Another explanation might be that, because older patients might be reluctant to disclose their MH issues, GP might integrate MH treatment into their routine physical care consultations without necessarily recording a MD diagnosis in the health registry. Profile 2 follow-up care included more patients with common MD or SRD, and the least with serious MD. Common MD (e.g., anxiety and depressive disorders) are often associated to some physical symptoms such as sleep disorders, headaches, and gastrointestinal problems [77, 78], which might have contributed to the initial reasons for Profile 2 patients to consult a GP. Older patients [79] and those with co-occurring MD-chronic physical illnesses [80, 81] are often reported as being undertreated for MD. These patient characteristics (e.g., older age, chronic physical illnesses) associated with lower MH follow-up care might explain the higher risk of death in Profile 2 compared to 1 and 4. However, Profile 2 patients showed the lowest risk of frequent ED use and hospitalization for MH reasons, which might signify that their MD symptoms were not severe.

Profile 5 patients (15% of sample) received the least MH follow-up care and care with GP for prior physical conditions, and none of them had a prior high continuity of GP care; only 25% were registered in family medicine groups compared to 64% in Quebec’s general population [82]. MH follow-up care was mostly provided by physicians with ≥ 20 years seniority. The fact that Profile 5 included the most patients from rural areas may explain part of this result: according to a previous study, GP tend to retire later in those areas [83]. This profile included the most men, patients with SRD and SRD-MD (26%), and ranked second in patients age 12–29, who are known to use fewer outpatient services (often as a last resort [84]) and to be stigmatized for their SRD [85]. Profile 5 ranked first in materially deprived individuals, living in rural or metropolitan areas, and second in homelessness; however, it included the least patients with 2 + prior MD episodes. Compared to rural or other urban areas, in metropolitan areas more physicians work in walk-in clinics or in specialized care, dispensing brief interventions [52, 53] for the evaluation and emergency treatment of more complex cases or first MD episodes. Physicians with greater seniority might be involved in such settings or practices. Considering these conditions, it’s not surprising patients in Profile 5 showed the second highest risk of death. It ranked third in frequent ED use and hospitalizations.

Profile 4 patients (23% of sample) received high MH follow-up care by usual GP, and ranked first in family medicine group enrollment and prior high continuity of GP care for physical reasons. Most had common MD, were women, aged 45+, and showed the fewest co-occurring MD-SRD with or without chronic physical illnesses. They were also the least materially and socially deprived. These characteristics are typical of patients usually treated in primary care [86], women being more prone than men to consult GP [87] and GP being known to prefer treating less complex MD cases, such as patients with no serious MD or co-occurring MD-SRD [75, 88] that can be treated quickly – an advantage in busy private clinics [89, 90]. Profile 4 had the least patients living in university regions, where walk-in clinics and psychiatric care are more prevalent [91]. With better GP care received and patient conditions, Profile 4 patients ranked second lowest in frequent ED use and hospitalization, and were less likely to die than those of Profiles 2 and 3.

Profile 1 patients (1% of sample) were almost exclusively treated by their usual psychiatrist, with few of them receiving GP care, and they showed the worst health and social conditions (serious MD, personality disorders, suicide attempts, co-occurring MD-SRD, homelessness, social deprivation). Patients with these conditions are more likely to be treated by psychiatrists [92], so it’s not surprising that they received the most physician psychotherapy. These patients are also usually found to be undertreated by GP, even if they have a high risk of physical comorbidities [89, 90]. Close to half (40%) of Profile 1 patients were 12–29 years old, and one fourth of them (24%) were aged 12–17. Compared to other profiles, more of them lived in long-term facilities, probably youth centers or prisons. Priority might have been given to psychiatric care for first psychotic disorders [93] and youths in order to prevent MD deterioration and long-term severe disability – both key trends in current reforms [3, 94], as we know most MD appear during youth [95]. Profile 1 was more prevalent in university regions – in Quebec, about 60% of psychiatrists practice there [96, 97]. However, these patients received more intensive care by psychiatrists, were more likely to be frequent ED users and hospitalized, but less likely to die than Profiles 5, 2 and 3. Patients with Profile 1 characteristics are known to have frequent acute care use [98,99,100].

Profile 3 patients (11% of sample) received follow-up care by psychiatrists and GP who were not their usual physicians. More of them (76%) received prompt MH follow-up care, but they ranked second after Profile 4 for adequate MH follow-up care (91%), and third after Profiles 1 and 4 for continuous MH follow-up care (76%). Walk-in clinic practices are quite developed in Canada: about half of the 9,279 patients featured in a 2022 survey had received care in this setting over the previous year [101]. These clinics may offer excellent access to care, but continuity of care is minimal. In Quebec, patients who don’t have a GP are encouraged to always go to the same walk-in clinic, so medical records can be shared and continuity of care increased [102]. Psychiatrists who provide follow-up care in Profile 3 may also work more extensively in programs delivering specialized brief interventions [52, 53], or in collaborative care as respondent psychiatrists [103, 104]. Profile 3 showed the second least prior continuity of GP care for physical reasons. Even if the MH follow-up care these patients received was quite high, the therapeutic alliance (which implies the patient’s long-term conditions are known) and care coordination may have been lacking, as care was delivered through different physicians. In the 2022 Canadian survey [101], respondents reported that to have a clinician who knows them and their health conditions well was the most important aspect of their primary care experience. This does not align with what was offered to Profile 3 patients, a situation that may be explained by the fact Profile 3 ranked second in the number of homeless patients, with serious MD, personality disorders, or care provided in long-term facilities. Patients with these characteristics may have more difficulty finding usual physicians, especially GP, while those with borderline personality disorder often claim to be unsatisfied with services [99]. These conditions, when associated with more frequent suicidal behaviors, may explain why Profile 3 patients were the second most likely to be frequent ED users and hospitalized, and showed higher risk of death than Profiles 1 and 4 – though lower than Profile 5.

Study limitations and strengths

First, data from clinicians other than physicians (e.g., nurses, psychologists) were not available, thus underestimating “global” follow-up care provided by extended physician teamwork, and “usual GP” was a proxy of family doctor which only spent over a 3-year period. Second, MH follow-up care indicators were proxy for “best practices”. Even though patients with incident MD are quite vulnerable, some may not have needed such frequent or lengthy MH follow-up care. Third, some MD such as personality disorders [105] and SRD [106] are known to be underdiagnosed in health administrative databases, which can underestimate MD overall or overestimate incident MD. Fourth, the study assessed MH care provided to patients with various MD over a one-year period following an incident MD. Analysis for specific MD (e.g., depression) or other timeframes would likely deliver different results. Fifth, adverse outcomes were underestimated, as patients who died before the end of the MH follow-up care period or who were hospitalized for more than a third of the MH prompt, adequate or continuous MH follow-up care periods were excluded. Though such exclusions were necessary considering follow-up care was the main variable being measured, it also contributed to exclude patients with the worst conditions – especially in the case of patients who had died (3.2%), as patients with long hospitalizations only accounted for 0.03% of the cohort. Sixth, though for some patients follow-up care and outcomes were measured during the COVID-19 pandemic, access to physicians was not compromised as some switched to telephone or video consultations [43]. However, this situation may have led to an underestimation of frequent ED use [10, 107]. Seventh, study results may not be generalizable to other health systems, especially those with no public insurance for vulnerable populations. Finally, we could not compare the physician follow-up care profiles found here with previous literature due to the original nature of this study – which is one of its key strengths. Other main strengths were to identify profiles by considering the three MH follow-up care indicators (prompt, adequate, continuous) in the year following an incident MD, and to use a provincial health administration database that includes almost all of Quebec’s population in order to obtain a very large cohort of patients.

Conclusion

In Quebec, only a minority of patients received prompt, adequate or continuous MH follow-up care after an incident MD. Five profiles were identified: three showed a better quality of MH outpatient follow-up care (Profiles 4, 1, and 3, about one third of the cohort), and two more specifically involved usual physicians (Profiles 2 and 4, about two thirds of the sample). Risk of death was highest in Profiles 5, 2 and 3, which had the least MH follow-up care; frequent ED use and hospitalization were more associated with serious health and social issues (Profiles 1, 3, and 5). Training and incentives to treat more patients with MD or SRD may be recommended for GP, so they can serve Profiles 2 and 5 patients better. Profiles 5 and 1 may benefit from integrated MD-SRD treatments, with assertive community treatment added in for Profile 1. Enrollment with a usual physician and intensive case management may be promoted for Profile 3, and collaborative care for Profile 4. A better use of psychotherapy may be recommended for all profiles, whether delivered by physicians or other competent clinicians. Overall, physician follow-up care after a patient receives a MD incident diagnosis should be significantly improved in order to promote recovery.

Data availability

In accordance with the applicable ethics regulations for the province of Quebec, the principal investigator is responsible for keeping data confidential.

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Acknowledgements

We gratefully acknowledge the support of the Canadian Institutes of Health Research (CIHR) and the “Institut national de santé publique du Québec”.

Funding

This study was funded by the Canadian Institutes of Health Research (CIHR, grant number: 8400711).

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Authors and Affiliations

  1. Douglas Hospital Research Centre, Department of Psychiatry, McGill University, Montreal, QC, Canada

    Marie-Josée Fleury

  2. Institut national de santé publique du Québec, Quebec City, QC, Canada

    Louis Rochette & Victoria Massamba

  3. Douglas Hospital Research Centre, Montreal, QC, Canada

    Zhirong Cao & Guy Grenier

  4. Département de psychiatrie, Centre de recherche de l’Institut universitaire en santé mentale de Montréal, Université de Montréal, Montreal, QC, Canada

    Alain Lesage

Authors
  1. Marie-Josée Fleury
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  2. Louis Rochette
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  3. Zhirong Cao
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  4. Guy Grenier
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  5. Victoria Massamba
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  6. Alain Lesage
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Contributions

MJF designed the study. LR and ZC performed the statistical analysis. ZR prepared Fig. 1 and tables. MJF, GG and ZC wrote the main manuscript text, which was revised by LR, VM and AL. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Marie-Josée Fleury.

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Ethics approval and consent to participate

Ethics approval was provided by the research ethics board of the Douglas Mental Health University Institute (Project IUSMD #16–45). Since the information used came from a database covering almost the entire Quebec population, the consent to participate was not applicable.

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The authors declare no competing interests.

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Fleury, MJ., Rochette, L., Cao, Z. et al. Profiles of physician follow-up care, correlates and outcomes among patients affected by an incident mental disorder. BMC Prim. Care 26, 7 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12875-024-02674-0

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BMC Primary Care

ISSN: 2731-4553

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