Background

Mental health is a significant public health concern in Canada, with approximately 1 in 5 Canadians experiencing a mental illness every year [1]. Despite this access to mental health care is limited with studies estimating that only around 40–60% of people with a mental health problem seek professional assistance [2,3]. In 2018, an estimated 5.3 million Canadians reported needing help for their mental health in the previous year highlighting the widespread demand for mental health support across the Canadian population [4]. Alarmingly, nearly half of these individuals had their needs only partially met (1.2 million) or completely unmet (1.1 million), suggesting substantial gaps in service delivery for mental health. ⁴

In Canada, mental health care is provided by a diverse range of professionals, including psychiatrists, psychologists, social workers, nurses, and physicians [3]. These different providers differ not only in their training and scope of practice but also in funding and accessibility [5]. For example, family physicians and psychiatrists are typically publicly funded and can be billed directly to provincial and territorial health insurance plans whereas services provided by psychologists and social workers may require out-of-pocket payment or private insurance coverage [3]. These differences in cost of services may result in financial barriers for individuals seeking care. Furthermore, these differences have implications on who receives care, what kind of care is delivered, and how barriers to access may differ across populations. In recent years, the mental health service landscape in Canada has become increasingly complex with expanding roles in the mental health care for non-physician providers such as psychologists and social workers [5]. This change reflects both efforts to meet growing demand for mental health care, shifts toward evidence-based care, and interprofessional models of service delivery [6,7].

Previous research has shown that mental health care utilization is shaped by an interplay of need, enabling factors and predisposing factors, such as symptom severity, income, gender, education, cultural background, wait time, and costs [8–12]. Despite Canada having universal health insurance, disparities and inequities are still associated with the underutilization of mental health care services [8,11,13,14]. For example, previous research in Canada has found that individuals with higher education are more likely to utilize mental health services than those in less educated groups [11,13]. Likewise, previous research has found income-based inequity in access to mental health services [8,14]. Understanding which populations access specific types of providers is critical for informing mental health care and equity-focused policies. For example, investments in community-based providers such as psychologists and social workers may reduce reliance on primary care for mental health, improve continuity of care, and expand culturally appropriate service options [15–17].

A limitation in this research however is that most studies aggregate all types of mental health providers into one variable limiting the examination of differences in who accesses which services and under which circumstances. As a result, we lack nuanced understanding of how sociodemographic factors shape engagement with specific provider types, such as psychologists or social workers, whose roles and funding structures differ significantly from psychiatrists and family doctors. Furthermore, few studies have examined national level trends over time in provider specific mental health service use limiting our ability to assess how patterns have shifted in response to evolving service landscapes, policy changes, or public attitudes towards mental health. The data used in this study predate the COVID-19 pandemic, which led to rapid expansion of virtual mental health care and changes in service delivery across provider types. While these changes may have changed some patterns of mental health care access, pre-pandemic data remain important for establishing baseline trends and identifying structural inequities in mental health service use. Understanding these baseline patterns is essential for interpreting how access may have changed in the post-COVID-19 pandemic context.

To address these gaps, this study focuses on examining how sociodemographic and mental health characteristics are associated with mental health service use across four provider types (family doctors, psychiatrists, psychologists, and social workers) and trends in their use over time in Canada. By disaggregating service use by provider type, this research aims to uncover distinct access patterns across sociodemographic groups and inform efforts to promote equity in mental health care.

Methods

Results

Between 2007 and 2020, family doctors consistently accounted for the highest proportion of mental health service use in Canada in every cycle with over half of service users responding to having accessed a family doctor for mental health care (See Fig 1). Across all cycles, the rank order of providers was stable and the patterns of service use appeared relatively stable over time based on descriptive trends, although no formal statistical tests of differences across years were conducted.. The proportion of people who accessed care through psychologists and social workers showed a gradual increase over time, while the proportion of visits to psychiatrists remained relatively unchanged over time. A one-year divergence appears in 2017, with a temporary spike for psychologist and dips slightly for the other providers but by the next cycle (2019) the pattern returns with psychologist and social workers converging at similar levels. We interpret 2017 as single cycle fluctuation rather than a break in trend. Estimates are survey-weighted and reflect that provider contacts are not mutually exclusive.

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Fig 1. Past-12-month contact for mental health by provider, CCHS 2007–2019 (survey-weighted proportion).

https://doi.org/10.1371/journal.pone.0326556.g001

When examining weighted estimates of the number of Canadians accessing care, similar trends were observed (See Fig 2). The total number of individuals seeing family doctors for mental health reasons far exceeded those accessing psychologists, psychiatrists, or social workers. However, all provider types showed increases in absolute numbers over time reflecting increased mental service use overtime. Notably, a temporary drop in service use was observed in 2017 with a rebound by 2019 across all provider types, potentially reflecting data collection limitations in that survey cycle. Given each cycle of the CCHS has different weight calibrations and sample allocations, we believe this is a cycle level fluctuation rather than a structural change to mental health care use.

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Fig 2. Weighted number of Canadians reporting past-12-month mental-health contact by provider, CCHS 2007–2019.

https://doi.org/10.1371/journal.pone.0326556.g002

Table 1 presents the weighted characteristics of respondents who reported consulting a mental health professional in the past 12 months. The sample was predominantly women (65.9%) and individuals aged 18–49 years. Most respondents reported higher household incomes (≥$80,000; 60.1%) and post-secondary education (87.1%). The majority identified as non-visible minorities (86.2%) and non-immigrants (83.7%), with 5.0% identifying as Indigenous. Most participants reported good or very good general (67.5%) and mental health (62.2%). Adjusted associations between sociodemographic and mental health characteristics and provider-specific mental health service use are presented in Table 2. Because outcomes were modeled separately the estimates below should be interpreted as provider-specific associations.

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Table 1. Weighted characteristics of study sample (CCHS 2019-2020).

https://doi.org/10.1371/journal.pone.0326556.t001

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Table 2. Adjusted associations between sociodemographic variables and mental health provider specific mental health service use.

https://doi.org/10.1371/journal.pone.0326556.t002

Use of social workers was higher among women (AOR = 1.19, 95% CI: 1.02–1.40) and decreased with age across all groups relative to the 12–17 group (AOR [18–34] = 0.49, 95% CI: 0.38–0.63; AOR[35–49] = 0.38, 95% CI: 0.30–0.49; AOR [50–64] = 0.25, 95% CI: 0.18–0.33; AOR [65+] = 0.21, 95% CI: 0.16–0.29). Better perceived mental health was associated with lower odds compared to having poor perceived mental health (AOR [good] = 0.65, 95% CI: 0.49–0.87; AOR [very good] = 0.63, 95% CI: 0.46–0.86; AOR [excellent] = 0.64, 95% CI: 0.44–0.94).

Use of family doctors was higher among women than men (AOR = 1.21, 95% CI: 1.05–1.39) and increased sharply with age (vs. 12–17: AOR [18–34] = 2.97, 95% CI: 2.26–3.91; AOR[35–49] = 3.74, 95% CI: 2.86–4.90; AOR [50–64] = 3.98, 95% CI: 3.01–5.26; AOR [65+] = 4.82, 95% CI: 3.59–6.47). Higher household income was associated with higher odds of using a family doctor (vs. No income or less than $20,000. AOR[$40–59k]: 1.53, 95% CI:1.15–2.03; AOR[≥$80k]= 1.41, 95% CI: 1.11–1.80), whereas post-secondary education was associated with lower odds compared to those with less than secondary school graduation (AOR = 0.61, 95% CI: 0.45–0.83). Not being a visible minority was also associated with higher odds of seeing a family doctor (AOR: 1.37, 95% CI: 1.06–1.77). Better perceived mental health related to lower use compared to having poor perceived mental health (AOR [very good] = 0.57, 95% CI: 0.42–0.78; AOR [excellent] = 0.58, 95% CI: 0.41–0.84).

Odds of seeing a psychiatrist were lower for women than men (AOR = 0.66, 95% CI: 0.55–0.79) and lower for adults aged 35–49 relative to 12–17 (AOR = 0.62, 95% CI: 0.42–0.91). Higher income was associated with lower odds (vs. No income or less than $20,000. AOR [$40–59k] = 0.70, 95% CI: 0.50–0.97; AOR [$60–79k] = 0.60, 95% CI:0.42–0.85; APR [≥$80k] = 0.66, 95% CI: 0.50–0.86). Better perceived health and perceived mental health related to lower use (e.g., perceived health excellent vs poor perceived health. AOR = 0.34, 95% CI; 0.22–0.52; perceived mental health excellent. AOR = 0.24, 95% CI: 0.16–0.37).

Psychologist use declined at older ages (AOR [50–64] = 0.69, 95% CI:0.52–0.92; AOR [65+] = 0.33, 95% CI: 0.24–0.45) compared with the 12–17 age group. In contrast, post-secondary education was associated with higher odds (AOR = 1.83, 95% CI: 1.12–2.98) compared to those with less than secondary school graduation. Being non-indigenous was associated with higher psychologist used compared to indigenous groups (AOR: 1.58, 95% CI: 1.13–2.23). Excellent perceived health was also associated with higher odds compared to those with poor perceived health (AOR: 1.47, 95% CI: 1.01–2.15).

Across providers, immigrant status was not significantly associated with mental health service use. Household income showed no association with psychologist or social worker use. Being a visible minority and Indigenous identity showed no associations overall, with two exceptions (respondents who were not a visible minority having higher odds of family-doctor use and non-Indigenous respondents having higher odds of psychologist use).

Discussion

This study examined national trends in mental health service use across four provider types (family doctors, psychiatrists, psychologists, and social workers) and identified sociodemographic predictors to accessing each provider using a recent nationally representative survey. Results show that family doctors were the most common provider for mental health, followed by psychologists and social workers, while psychiatrists are accessed less frequently. These trends were generally stable over time, with increases in psychologist and social worker use observed between 2017 and 2019. Consistent with previous research, family doctors were found to be the most commonly accessed mental health care provider, reaffirming the central role of primary care in Canada’s mental health system [5,18]. Given the high rates and numbers of people who seek mental health care from family doctors it is important that family doctors are trained in assessment and treatment of mental health [19]. Access to psychologists and social workers increased in recent years, particularly between 2017 and 2019, which may reflect changing public attitudes toward mental health, reduced stigma, and increased availability of services [20–22].

An important consideration in interpreting these findings is that the data reflect pre-pandemic patterns of mental health service use. The COVID-19 pandemic led to a multitude of changes in mental health care including the expansion of virtual care and telehealth services, which may have altered access to different provider types [23]. For example, virtual care may have reduced some geographic barriers while potentially introducing new challenges related to technology access, digital literacy, and privacy [23]. Despite these changes, many structural features of the Canadian mental health system such as differences in public versus private funding and provider availability remain largely unchanged. Because of this the patterns observed in this study likely reflect underlying systemic dynamics that continue to shape access to care. Likewise, these findings provide an important baseline for understanding how mental health service use has evolved in the post-COVID-19 pandemic era.

Logistic regression analyses from the 2019–2020 CCHS cycle indicate significant differences in access to providers across different demographic groups. Women had higher odds of seeking support from family doctors and social workers compared to men, aligning with prior literature showing greater mental health service use among women [24]. Age emerged as a significant predictor of provider type with older adults more likely to seek care from family doctors and younger individuals more likely to access psychologists and social workers. This trend may reflect generational differences in mental health literacy, familiarity with provider types, and access pathways [25,26]. Additionally, mental health services delivered by psychologists and social workers are not universally covered by provincial health plans in Canada, and younger individuals may access these providers through post-secondary institutions, school-based programs, or employee insurance plans [8,27]. The rise in mental health awareness among younger generations, combined with greater comfort in discussing psychological issues, may also increase their likelihood of seeking specialized care [28,29]. In contrast, older adults may be more affected by stigma surrounding mental illness and thus prefer family doctors who can address mental and physical health simultaneously in a less stigmatizing setting [26]. Furthermore, these age patterns likely also reflect differences in care continuity and navigation. Older adults have stronger ties to a usual family doctor and more multimorbidity which makes primary care a natural entry point for mental and physical concerns [26]. Younger adults in contrast more often have access to private insurance and Employee Assistance Programs (EAP) for counselling which may lower the threshold to see psychologist and social workers.

Income and education were associated with distinct patterns of provider use. Individuals with higher education were more likely to access psychologists, potentially reflecting the private-pay nature of these services and barriers related to insurance coverage [8,30]. In contrast, individuals with lower income and education levels were more likely to see family doctors or social workers, who are often covered under public or community-based services. These patterns highlight ongoing structural inequities in access to mental health care, where the ability to pay often determines the type and intensity of support received [8,30–32]. These findings support the need for publicly funded access to a broader range of providers to ensure that individuals are matched to appropriate services regardless of ability to pay. Specifically, in Canada psychologist and social workers are not universally covered and access often depends on employers benefits, EAPs, or private insurance which commonly cap the number of sessions [33]. By contrast, visits to family doctors and psychiatrist are publicly insured which may explain a shift towards these providers among lower income groups.

Self-perceived mental and general health status were also associated to provider use. Individuals who rated their mental health as poor had significantly higher odds of accessing all four types of mental health providers. However, the findings also reveal potential disparities in access as those who were not visible minorities had higher odds of accessing family doctors and non-Indigenous individuals were more likely to access psychologists. These results align with existing literature documenting racial and cultural inequities in mental health service access in Canada, driven by factors such as discrimination, mistrust of providers, culturally unsafe care, and underrepresentation of racialized and Indigenous practitioners [34–37]. Furthermore, these disparities are also shaped by geography and provider supply [38,39]. For example, mental health care providers are often concentrated in large urban centre resulting in longer travel times and indirect costs for rural communities to accessing care [40]. These findings underscore the importance of promoting equitable mental health services and support community-based models of care that are grounded in trust and cultural responsiveness. Several actions could improve equitable access to mental health services in Canada. First, expanding publicly funded, evidence-based psychotherapy would reduce the role of financial barriers [38]. Second, integrating mental health care providers into primary care teams by streamlining referrals, provided shared care can result in shortened wait times and improved continuity in care [5,18]. Equity can be further strengthened through Indigenous-led services, cultural-safety standards, language interpretation, and navigation supports for newcomers and racialized communities. Furthermore, private insurance and EAPs need to be modernized to ensure adequate session coverage. Lastly, further investment needs to be made in community-based mental health care including walk-in counselling, youth hubs, peer and Indigenous led programs and system navigation would expand timely service and reduce avoidable reliance on emergency and specialist services [15,17]. These findings reveal an inequitable mental health care system in Canada, where sociodemographic factors such as age, gender, income, education, and racial identity shape not only access but also the type of provider individuals are able to see. While need-based access patterns were evident there are clear structural and systemic barriers that limit equitable engagement with care. These disparities reinforce the importance of expanding publicly funded mental health services beyond primary care and ensuring broader access to psychologists and social workers. As Canada continues to build toward a more integrated and accessible mental health system, efforts must prioritize reducing financial, geographic, and cultural barriers to ensure that all individuals can access the mental health care they need. Future research should explore the intersection of provider preferences, treatment experiences, and long-term outcomes to further inform changes to the mental health care system.

Supporting information