title: Measuring the effect of a large reduction in welfare payments on mental health service use in welfare-dependent neighborhoods.
abstract: BACKGROUND
  Major social policy changes were implemented in Canada in the last decade with few efforts to examine their potential health effects.
  
  
  OBJECTIVE
  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.
authors.affiliation: Department of Family and Community Medicine, University of Toronto, and Inner City Health Research Unit, St. Michael's Hospital, Toronto, Ontario, M4X 1K2, Canada. leah_steele@camh.net
authors.forename: Leah S
authors.initials: LS
authors.lastname: Steele
authors.forename: Richard H
authors.initials: RH
authors.lastname: Glazier
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Lin
authors.forename: Peter C
authors.initials: PC
authors.lastname: Austin
authors.forename: Cameron A
authors.initials: CA
authors.lastname: Mustard
mesh_terms: D003156:Community Mental Health Services / Q000191:economics / Q000706:statistics & numerical data*; D016001:Confidence Intervals; D006301:Health Services Needs and Demand / Q000639:trends; D006302:Health Services Research; D006801:Humans; D001523:Mental Disorders / Q000191:economics* / Q000453:epidemiology / Q000628:therapy; D016017:Odds Ratio; D009819:Office Visits / Q000191:economics / Q000706:statistics & numerical data*; D009864:Ontario / Q000453:epidemiology; D011203:Poverty; D011632:Public Assistance / Q000331:legislation & jurisprudence*; D012946:Social Welfare / Q000191:economics / Q000331:legislation & jurisprudence*; D012949:Social Work, Psychiatric / Q000191:economics*; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D013997:Time Factors