Psychiatry and Primary CareReceiving treatment for common mental disorders☆
Introduction
The most common mental disorders in the general community are depressive and anxiety disorders. A worldwide WHO study [1] showed a considerable 1-year prevalence range across countries, from 4.3% to 26.4%. But at each of the 14 sites involved, anxiety disorders (2.4–18.2%) and depressive disorder (1.7–9.8%) ranked in the first two places. Comparable figures were replicated in the European Study of the Epidemiology of Mental Disorders [2], the Australian National Survey of Mental Health and Well-being [3], the US National Co-Morbidity Study [4] and the Dutch NEMESIS study [5].
Many depressive and anxiety disorders are presented by somatic symptoms, which is seen as a reason for not recognizing these disorders [6]. Consequently, many of these disorders remain untreated. In the Dutch population-wide survey of 1996 [5], only 34% of those with at least one mental health disorder reported some form of care (including informal care); 27% had been treated in primary care and 16% in ambulatory or residential mental health care. Kessler et al. [7] reported that in the US less than 40% of those with serious mental illness received treatment [7]. In the European study [8], 26% of those with a diagnosis of mental disorder did consult a formal health service for their mental health. In the WHO study [1], [9] mentioned above, 1% (Nigeria) to 15% (USA) of all cases received help. Taking only severe cases, the range of received treatment varied between 15% (Lebanon) and 65% (Spain) with a median of 51% (Netherlands, USA).
Up to now, epidemiological studies have provided a limited understanding of the patient characteristics, related to treatment reception. Women, 35–55 year olds, people in cities, single persons and unemployed or disabled persons, patients with more severe disorders and patients with comorbidity were more likely to access some kind of care [5], [10], [11], [12].
Attention has been focused on clinical, socioeconomic and socio-demographic characteristics. Little attention has been paid to psychological factors such as beliefs, values and personality as determinants of help-seeking behavior. Jorm et al. [13], [14] called attention to a widespread misunderstanding among the public about the prognosis, benefits and risks of mental health treatments which might easily constitute a barrier to help-seeking. Similarly, little attention has been paid to the patient's perspective. Clinical need has always been assessed by means of standardized instruments that can be characterized as symptom inventories. The need for care — as the patient perceives it — remained out of focus. In the same realm are patients' earlier experiences with mental health care, as these might also explain current help-seeking behavior [15]. Negative experiences in the past may prevent future help-seeking behavior, and thus treatment, as well.
This paper adds to this deficit in the literature by applying the behavioral model of Andersen et al. [16], [17]. This model distinguishes three groups of determinants for the use of services: determinants that contribute (a) to people's disposition to use services, (b) factors that enable the use of services and (c) factors that determine the need for care. Also, the interaction between several determinants of the help-seeking process can be studied within the behavioral model of Andersen.
Among the Predisposing characteristics, demographic factors and personality characteristics are counted as well as people's attitudes, beliefs and values regarding mental health care. The Enabling factors indicate availability of care and include geographical (distance) and financial (insurance, income) access to institutions. The Need for care can be divided into need for care from the patient's perception (the perceived or subjective need for care) and the need for care as assessed by the clinician (clinical or objective need for care). Clinical need for care has a number of indicators: the diagnosis, severity, presence of co-morbidity and recurrence.
Originally, the model was intended to evaluate the ‘equity’ of health care systems. Equitable access is defined by Andersen [17] as “occurring when demographic and need variables account for most of the variance in utilization”. Analyzing use of services within the broader context of need, predisposing and enabling factors makes it possible to detect imperfections within the functioning of the mental health care system.
In this paper, we will look for patient characteristics that increase the chances of receiving treatment for the most prevalent mental disorders: depressive and anxiety disorders. We will apply Andersen's model with special attention for psychological characteristics and the patient's perspective among the predisposing characteristics.
Our research question is: to what degree is the use of mental health services by persons with depressive and/or anxiety disorders explained by
- 1.
predisposing characteristics (socio-demographics, personality, beliefs about mental health care, evaluation of mental health care received in the past);
- 2.
enabling characteristics (availability of facilities, access to facilities, income); and
- 3.
need characteristics (self-perceived need, type and severity of disorder, psychiatric comorbidity, somatic comorbidity)?
Section snippets
Design
Data on the use of health services were collected in the Netherlands Study of Depression and Anxiety (NESDA, http://www.nesda.nl). NESDA is a multi-centre study designed to examine the long-term course and consequences of anxiety and depressive disorders. Within the NESDA framework, 743 patients with a DSM-IV diagnosis of mood or anxiety disorder in the past 6 months were recruited in primary care settings. For a more detailed description of this study, see Ref. [18].
This primary care sample
Results
Table 1 shows the composition of psychopathology in the study sample. Almost 80% of the persons suffered from anxiety disorder and a smaller proportion of nearly 60% had had one or more depressive disorders during the past 6 months. More than one third of the sample showed co-morbidity of depressive and anxiety disorder during the past 6 months.
Summary of main findings
Our study indicated that 57% of patients with a diagnosis of anxiety or depression who recently visited their GP had received professional treatment, mostly (50%) in primary care, especially with their GP. Fourteen percent of them had contacted a specialist mental health care professional and another 14% reported having received treatment from another kind of medical doctor, mostly a company doctor. Forty-three percent of these patients had not had any professional contact regarding their
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Cited by (0)
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The infrastructure for the NESDA study is funded through the Geestkracht program of the Dutch Scientific Organization (ZON-MW, grant number 10-000-1002) and matching funds from participating universities and mental health care organizations (VU University Medical Center, GGZ Buitenamstel, GGZ Geestgronden, Leiden University Medical Center, GGZ Rivierduinen, University Medical Center Groningen, Lentis, GGZ Friesland, GGZ Drenthe).
Specific analysis for this paper has been made possible by grant number 945.144.13 in the Program “Efficiency” of ZON-MW.