This study captured information early in the COVID-19 pandemic (May to December 2020) and found that 6.3% of respondents reported MHSU. This estimate is lower than the 13.5% reported in a Canadian survey [29] carried out between October and December 2020. The higher estimate in the latter study may in part be explained by the fact that it included twice and five times the percentage of individuals with moderate/severe depression and anxiety, respectively.

Study findings showed the importance of need factors in explaining MHSU, controlling for predisposing and enabling factors, which has been previously reported [16]. Perceived mental health status and presence of anxiety and depression symptoms have been associated with increased MHSU [1, 16]. To our knowledge, there are no general population studies that have looked at MHSU and changes in self-reported mental health status. We observed that individuals reporting no change in their mental health, during as compared to prior the pandemic, were not more likely to report MHSU, whereas individuals with an improvement in their mental health were more likely to report MHSU. A Canadian survey during the second wave of the pandemic showed a higher proportion of individuals aged 35 to 64 years reporting poor or fair mental health as compared to the year prior to the pandemic during which, up to 25% reported a mental health need for care [30]. Although the cross-sectional nature of the current study design precludes concluding on causality, these findings suggest the importance of receipt of mental health services in improving perceived mental health. In a recent longitudinal study in community primary care older adults, minimally adequate care for depression and anxiety was associated with improved self-reported mental health outcomes, such as life satisfaction and health related quality of life [31].

In this study, close to one in five respondents reported an increase in alcohol consumption from prior to the pandemic, and this was not associated with MHSU. In general, individuals with alcohol-related problems are not more likely to report MHSU [32], but when they do use health care services, it is usually for the physical problems related to alcohol consumption [33]. Canadian surveys conducted between April and December 2020 showed that between 28% and 32% of respondents reported an increase in alcohol consumption [3, 29]. When reporting on older adults specifically, only 20% had reported an increase in either alcohol or cannabis use [29]. The lower rate observed in this study sample may be explained that it was comprised of a larger proportion of older adults. The observations on need factors were similar for each regional cohort studied. As evidenced by a systematic review on the predisposing, enabling, and need factors, the latter were the most consistently associated with MHSU [16].

Overall, among the enabling factors studied, controlling for need and predisposing factors, receipt of informational/financial/practical support was associated with increased MHSU, similarly reported in a previous Canadian population-based study [32]. When looking at reported income in the year prior to the pandemic, in general, findings from this study did not show significant income-related inequalities in MHSU [34]. In the few instances where income was associated with MHSU, differences observed did not favor participants who reported higher income levels. In previous Canadian population-based studies, income was not associated with overall MHSU and specifically with use of general practitioners and mental health specialists, such as psychiatrists [1, 32]. Canada has a public health system where residents are covered for the majority of their medical consultations with physicians. Consultations with health professionals working in the private sector would therefore not be covered under the public health system. A decrease in income during the pandemic was marginally associated with a reduced likelihood of MHSU in the overall sample and significantly in the Ontario Health Study. This finding may suggest the presence of socio-economic barriers in mental health care access related to job loss and employee health benefit coverage. In fact, during the second wave of the pandemic, about one in 5 Canadians reported a mental health need, with counselling or therapy being the most common [30]. Barriers to accessing these services included, among others, income and lack of insurance coverage [30]. Population studies prior to the pandemic also showed that income was associated with consulting mental health professionals [32] and that out-of-pocket costs related to psychological services were a barrier in receiving psychotherapy [35]. Income-based inequities in the use of psychological services and psychotherapy reported in Canada are also greater than those observed in other countries with a general practitioner gatekeeper system [23]. Future research should focus on better describing the reasons for the absence of mental health service use. This may help better identify the ‘health care system and individual circumstances’ that act as barriers to mental health care [36].

Among predisposing factors studied and after controlling for enabling and need factors, age and gender, as well as alcohol consumption and cannabis use were associated with MHSU. Older adults aged 65 years and over were less likely to consult than other age groups, a finding similarly reported during the pandemic in Canada [10] and elsewhere [11, 37]. Increased resilience mitigating the mental health effects of COVID-19 in older adults has been put forth as a possible explanation [38]. Another Canadian survey conducted during the pandemic also showed better coping skills and mental health in older adults in comparison to younger adults [29]. Alternatively, the decreased MHSU observed may in part be related to fear of infection, also evidenced by many older adults interrupting their home care services due to this reason [39]. Similarly to what has been reported elsewhere [10], females and other gender minority groups were more likely to use mental health services even after controlling for need factors.

Further, lifestyle behaviours such as alcohol consumption in the current study was associated with reduced MHSU, which has been previously reported in other Canadian studies [2, 32]. These findings may also reflect the fact that daily alcohol consumption was found to be more prevalent in adults aged 45 years and over (14.4%) as compared to younger adults aged 35 to 44 years (5.8%), and these adults aged 45 years and over were also less likely to report MHSU (5.9% vs. 15.9%). Additional post-hoc stratified analyses by age group showed that among the adults aged 35–44 years, respondents reporting less than daily and almost daily alcohol consumption were not more likely to report MHSU, as compared to those not reporting past-year alcohol consumption. Among participants aged 45 years and over, respondents reporting less than daily and almost daily alcohol consumption were less likely to report MHSU, as compared to respondents not reporting past-year alcohol consumption. Studies have similarly shown that adults aged 55 years and over are less likely to report problematic substance use disorders [29, 40] and consequently less likely to consult mental health services. The current observation where alcohol consumption is associated with lower MHSU may also suggest the presence of maladaptive behaviours during the pandemic and the presence of unmet mental health care need. In fact, when looking at the need factor, participants reporting an increase in alcohol consumption since March 2020 were not more likely to consult for mental health reasons. In this study, however, past-year cannabis use was associated with increased MHSU, with a larger proportion from the younger age group. Other studies show that two out of five users of cannabis also reported increased and problematic use during the pandemic [29].