World Health Organization Collaborating Centre, School of Psychiatry, UNSW at St Vincent's Hospital, Sydney, Australia
Faculty of Medicine and Health Sciences, University of Newcastle, NSW, Australia
Correspondence: Professor Gavin Andrews, The University of New South Wales, School of Psychiatry, Clinical Research Unit for Anxiety Disorders, 299 Forbes Street, Darlinghurst, New South Wales 2010, Australia. E-mail: gavin{at}crufad.unsw.edu.au
Declaration of interest None. Funding detailed in Acknowledgements.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To explore some reasons for the poor treatment coverage for mental disorders in developed countries.
Method Data were taken from Australian national surveys and from the World Health Report.
Results Only one-third of people with a mental disorder consulted. Probability of consulting varied by diagnosis: 90% for schizophrenia, which is accounted for by external factors; 60% for depression; and 15% for substance use and personality disorders. The probability of consulting varied by gender, age, marital status and disability, from 73% among women aged 25-54 years, disabled and once married to 9% among males without these risk factors. Those who did not consult but were disabled or comorbid said that they "preferred to manage themselves". Data from five countries showed no evidence that overall health expenditure, out-of-pocket cost or responsiveness of the health system affected the overall consulting rates.
Conclusions Societal, attitudinal and diagnostic variables account for the variation. Funding does not. Public education about the recognition and treatment of mental disorders and the provision of effective treatment by providers might remedy the shortfall.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Analysis
Dependent variables
Three planned analyses were conducted to examine service utilisation and
type of treatment received (see Fig.
1).
|
In the text, therefore, mental health consultations refer to all consultations for mental health problems regardless of the type of health professional consulted.
Coding of mental disorders
For analysis of service utilisation in the whole sample, DSM-IV mental
disorders were coded in three levels: no disorder,
sub-threshold disorder (i.e. answered yes to criterion A
questions but failed subsequent criteria) and met full criteria for
disorder. Respondents who met the criteria for at least one DSM-IV
mental disorder were coded against their principal current disorder, that is,
respondents were coded against their only disorder when they met the criteria
for one disorder or against the disorder "that troubled them the
most" where respondents met the criteria for more than one disorder.
This coding strategy ensured that service use for mental health problems was
counted against the respondent's most clinically significant mental disorder
and that no person was counted twice. Psychosis and cognitive impairment were
included in the calculation of service utilisation for any mental disorder
(n=2352; Tables 1 and
2) and they were not included
in subsequent analyses. Data on a larger sample of persons with psychosis are
available from the parallel Low Prevalence Disorders Survey
(Jablensky et al,
2000).
|
|
Calculation of odds ratios
Odds ratios (ORs) were calculated from logistic regression models with
dependent variables as described above. Standard errors around proportions and
confidence intervals around ORs were calculated using jack-knife repeated
replication to account for the complex survey design
(Kish & Frankel, 1974).
The SUDAAN software package, designed for use with complex survey samples, was
used for these calculations (Shah et
al, 1997).
Model-building processes
For each regression model, independent variables were examined in three
groups: socio-demographic correlates; disability and neuroticism; and mental
and physical disorders. The first stage of the analysis examined each group of
variables separately to determine their contribution to each model. Any
variable that did not contribute significantly to the model fit (P
< 0.05) was eliminated from further analyses. In the second stage of the
analysis, significant variables from each group were entered into a final
model so that the effects of each variable could be examined after controlling
for all other significant variables. All models that contained mental
disorders as independent variables controlled for the presence of physical
disorders. The regression coefficients from the model for the principal
complaint then were used to calculate the predicted probability of consulting
among different risk groups (see Fig.
2).
|
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
More than half (61%) of those with a mental disorder who sought treatment for mental health problems reported receiving medication or tablets and 57% reported non-specific counselling ("help to talk through your problems"). People with sub-threshold or without disorder were treated similarly, as though a "prescription and a chat" was the stock in trade of doctors being consulted for a mental health problem, whether or not the person met the criteria for a diagnosis. Correlates of treatment-seeking in the whole sample are presented in Table 2.
Socio-demographic correlates
Women were more likely to consult than men (OR=1.90), those aged 25-54
years compared with those aged 18-24 years (OR=1.84-2.32) and persons who were
previously married (separated, widowed or divorced) compared with persons in a
married or de facto relationship (OR=1.42). Less education was
associated with service use (OR=0.54-0.57). Employment status was a
significant correlate of service use in early analyses but was not significant
once the model controlled for disability, neuroticism and mental
disorders.
Disability and neuroticism
Higher levels of disability (or lower levels of functioning) on both the
physical and the mental health scale of the SF-12 were associated with
consultation for mental health problems (OR=0.87 and 0.63, respectively). Even
so, only 52% of people with a disorder and moderate or severe disability
(SF-12 < 40) consulted for a mental problem.
Mental disorders
The odds ratios for consulting for subthreshold and full-criteria disorders
were 2.93 and 7.83, respectively. When the relationship between probability of
mental health consultation and type of disorder was examined, the presence of
both subthreshold and full-criteria disorders was significantly associated
with service use for anxiety and affective disorders but not for substance use
disorders or somatoform disorder. Personality disorders were not associated
with service use in earlier analyses (2=2.68,
P=0.262) and therefore they were not included in the final model.
Comorbidity, measured by the number of disorders for which respondents met the
criteria, was significantly and independently associated with service
utilisation for mental health problems (
2=454.4, P
< 0.001) and odds ratios increased with the number of disorders. The
presence of a physical disorder was not significant in any of the models
tested.
The regression coefficients from the model were used to define the probability of consulting for a mental health problem. Risk factors for consulting identified in the model were added in descending order of importance. The lowest predicted consulting rates were 5% for males under 24 or over 55 years, who had only one disorder, no disability, lower neuroticism, no physical health disability, were married or never married and not educated beyond high school. The highest rates (91%) were in females aged 25-54 years in whom all the above risk factors were present.
Service utilisation among those with a current principal disorder
(n=1422, Fig. 1, box
2)
Comorbidity, with other mental disorders and/or with physical disorders,
was not uncommon. We wanted to explore service use with respect to the
clinically significant disorder for which people would seek help. Box 2 of
Fig. 1 therefore illustrates
the treatment of people with current symptoms who, if they met the criteria
for more than one disorder, identified their main disorder as the one that
"troubled them the most". Cases of psychosis and cognitive
impairment (prevalences of 0.4% and 1.3%, respectively) were included in the
previous analysis but were deleted from this and subsequent analyses because
we had doubts about their ability to identify their main disorder
appropriately.
Half of those who met the criteria for a mental disorder during the year reported symptoms in the past month. Only 37% of these current cases had consulted for mental health problems in the 12 months prior to interview. Moreover, only one-fifth (22%), reported receiving a treatment for which there is evidence of efficacy (medication or cognitive-behavioural treatment). Whether they actually received effective treatments and complied is not known. Sixty-five per cent of respondents who had not sought treatment for a current disorder said that they had no need. Only 6% reported a need for treatments believed to be efficacious, defined above as receiving either medication or cognitivebehavioural therapy (see Nathan & Gorman, 1998).
Mental health consultations by those with current principal disorders are presented in Table 3. Consultation was highest among affective disorders (66.8%) and lowest among substance use (14.7%) and personality disorders (19.1%). Eighty per cent of all consultations were with people with anxiety and depressive disorders. Consultation with mental health professionals also was highest among those with affective disorders (24.4%). The most common interventions reported across all disorders were medication and non-specific counselling, although one in five reported receiving cognitivebehavioural therapy and an equal number psychotherapy.
|
The number of mental health consultations in the year ranged from a mean of 9.3 for affective disorder to 6.6 for substance use disorders. All the distributions were skewed and the medians were lower. Ten per cent of the consultees utilised 37% of the services and averaged 26 visits per year, principally to psychiatrists. Eighty-six per cent of these high utilisers nominated anxiety or depression as their principal complaint.
Socio-demographic correlates
These were similar to those reported for the whole sample
(Table 2). Women were more
likely to consult than men (OR=1.60), those aged 25-54 years than those aged
over 65 years (OR=3.23-3.97) and persons who were separated, widowed or
divorced than those in a married or de facto relationship (OR=1.65).
Although employment status showed a significant relationship in earlier models
(2=12.14, P=0.007), it was not significant once other
variables were added to the model (
2=2.04,
P=0.564).
Disability and neuroticism
Greater disability on the SF-12 measure was associated with consulting for
mental health problems. Neither physical disability nor neuroticism was
significant in the final model (2=2.52, P=0.113 and
2=2.99, P=0.084).
Mental disorders
Those with anxiety, personality or substance use disorders were all less
likely to consult for mental health problems compared with those with a
principal diagnosis of an affective disorder (OR=0.22-0.49). Respondents with
two, three or more disorders also were more likely to consult than those with
only one disorder (OR=1.83 and 4.16, respectively). The presence of a physical
disorder was not significant in any of the models tested.
The regression coefficients from the model were used to calculate the predicted probability of consulting (Fig. 2). The probability of consulting was determined by the type of principal disorder and by age (25-54 years), gender (female), marital status (separated/divorced/widowed) and mental health disability score (SF-12<40). The probability of consulting for an affective disorder was 67% and the predicted probability varied between 32% and 85% according to the presence of the above risk factors. The predicted probabilities of consulting for all five groups of disorder when identified as a main complaint are shown in Fig. 2, with the difference that each risk factor makes added to the baseline. The addition of comorbidity, which is a strong determinant of consulting, makes little difference to the predicted probabilities in Fig. 2, presumably because the effect is now subsumed by disability.
Perceived need for care among those with a current principal disorder
who did not seek treatment (n=836,
Fig. 1, box 3)
People who met criteria for a mental disorder and who had not sought help
were asked if they had perceived a need for treatment for their symptoms
(Table 4). Perceived need for
treatment was highest among affective disorders (58%) and lowest among
substance use disorders (15%). The most commonly reported need was for
counselling (this section of the interview grouped psychotherapy,
cognitivebehavioural therapy and non-specific counselling together).
The perceived need for medication was relatively low (9.6% and 15.7%) in
contrast to doctors' usual response when consulted for a mental problem. The
correlates of perceived need for care among those who did not seek treatment
are little different from those derived from the whole group
(Table 3) and are available
from the authors. Some of the 836 people who did not seek treatment did not
have disorders that were disabling. We therefore suggest that health services
should not be primarily concerned for such people and that the provision of
written, videotaped or web-based self-help materials could suffice
(Gould & Clum, 1993).
|
Respondents with disability or comorbidity with a perceived need for
treatment
A total of 314 (36%) reported a perceived need for treatment and 62% of
this group either met the criteria for more than one mental disorder and/or
had moderate or severe disability (SF-12<40). These people should be a
priority target of treatment. This disabled and comorbid group
was asked why, given seeing that they had specified some need for treatment,
they did not get that treatment. Of those who did not get treatment but had
identified medication as a need, 61% said they did not get it because they
preferred to manage themselves. Of those who identified counselling as a need,
42% said they did not get it because they preferred to manage themselves.
Independence or stoicism is a laudable trait unless it interferes with relief
of a disabling disorder, in which case it is self-defeating.
Respondents with disability or comorbidity with no perceived need for
treatment
Over 500 hundred people (5%) from the total population surveyed met the
criteria for a mental disorder, did not seek treatment and said they had no
need for treatment. Again, there were many who had no comorbidity or
disability and self-help materials might well be appropriate for them.
However, one-third (168/522) met the criteria for more than one disorder
and/or had moderate or severe disability, reporting that they had been unable
to work or had to cut down on what they did 6.6 days out of the previous 28
days. They, too, should be a target for treatment. Because they had not
specified any need for treatment, we were unable to ask about the barriers to
treatment, but we could compare their socio-demographic characteristics with
the people with comorbidity and/or disability who had sought treatment. They
were more likely to be males (2=15.9, d.f.=1,
P<0.001) and under 24 or over 65 years (
2 for all
levels of age=11.9, d.f.=5, P=0.06) than the comparison group who had
sought treatment.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
We then analysed the patterns of consulting (except for psychosis and cognitive impairment) among those who met the criteria for a current disorder that they had identified as their principal complaint, comparing people who consulted with people who did not. Consultation rates were highest for affective and anxiety disorders, together accounting for 80% of all consultations for a mental problem by people who met the criteria for a mental disorder. We used the correlates of consulting to calculate a predicted probability among different risk groups. It ranged from a high of 85% among previously married women aged 25-54 years with an affective disorder and significant disability, to a low of 7% among married or never married males under 24 or over 65 years with a substance use disorder and mild disability. Medication and counselling were the treatments reported most commonly. Ten per cent, mainly people with anxiety and depression, accounted for 37% of all consultations and saw their doctor (often a psychiatrist) an average of 26 times a year. This may be evidence of a small group of patients being resistant to or non-compliant with effective treatments, being offered treatments that are not effective or some combination of these factors. It represents a reduction in service potential to other equally ill patients who might be expected to have a more prompt therapeutic response.
Nearly two-thirds of people with a current disorder did not consult and, although this might be acceptable for those without disability and comorbidity, it was not felt to be appropriate for the remainder. We therefore focused on this group of people with disability and/or comorbidity and had not sought treatment. We asked the people who expressed a need for treatment why they had not consulted and the majority said "I preferred to manage myself". We could not ask the people who had no perceived need why they did not get treatment but we did look at the demographics being male and aged 18-24 or over 65 years were the characteristics overrepresented.
Threats to validity
These data are based on self-report, both of the symptoms that could be
matched against diagnostic criteria and of the responses to the question
"Did you consult for a mental problem such as stress, anxiety,
depression or dependence on drugs or alcohol?". The main problem is the
screening interview used for psychosis
(Cooper et al, 1998).
In the present survey 43% of people identified by the psychosis screener
reported a mental health consultation, and even if the true figure is double
this, it would only add a further 22 people to those who consulted and would
not affect the overall consulting rate.
Effect of health system variables
Can these data be explained by system variables that determine access to
treatment? The World Health Report 2000
(World Health Organization,
2000) drew attention to the importance of system variables to
health attainment characteristics such as size of budget,
responsiveness to patient needs and fairness in financing health care; these
are all factors that determine the level of services available, the ease of
access and availability to the poor. Alegria et al
(2000) compared rates of
consulting for a mental problem among people who met the criteria for a mental
disorder in surveys in the USA, Canada and The Netherlands, three countries
with quite distinct methods of financing health care. The USA, which has the
largest health expenditure, is ranked first in responsiveness and yet had a
consulting rate among those who met the criteria for a mental disorder of only
22%. Canada and The Netherlands both spend half as much on health as does the
USA, are ranked 8th and 9th on responsiveness and had low rates of consulting
for mental problems: 22% and 32%, respectively. The UK, which spends one-third
of what the USA does on health, has the smallest out-of-pocket component (3%)
and ranks 27th on responsiveness, has a consulting rate among those with a
mental disorder of 23-27%. Bebbington et al
(2000) reported that 34% of
people identified as suffering anxiety or depression in the UK survey
consulted their general practitioners about a mental problem. We used
additional data to calculate pro rata values for all people with
mental disorders. These data, together with data from Australia, are shown in
Table 5, and no obvious lessons
emerge. The USA spends the most on health care (in dollars and as a proportion
of the gross domestic product), ranks first for responsiveness and yet only
22% of those with mental disorder consulted. The UK spends the least on health
care, ranks poorly on responsiveness, has the least out-of-pocket expenditure
and has a consultation rate that differs little from the USA. System variables
do not seem to influence the met need.
|
Consultations and illness type
People with psychosis have greatest contact with the health services
(Jablensky et al,
2000) and then there is a hierarchy, from affective disorders to
substance use disorders, over which the probability of consulting is reduced
sixfold.
Consultations and demographic variables
Howard et al
(1996) reanalysed the data
from the US Epidemiologic Catchment Area Program, Katz et al
(1997) reviewed the results of
the matched US National Comorbidity Survey and the Ontario Health Survey,
Bebbington et al
(2000) analysed the treatment
of anxiety and depression from the UK national survey and all, like the
present survey, found that only one group educated women of
child-rearing age consult appropriately. The other demographic groups
underconsult, with school-only-educated males without family responsibilities
consulting least. Some of this underconsulting in males is because they do not
recognise that they have an emotional problem
(Kessler et al, 1981)
but the specific age and gender relationship is such a consistent finding
across all studies that we wonder if there could be an overriding explanation.
Elsewhere, others (Jorm, 2000)
have argued for better mental health literacy for the general population, and
now we argue that it should be specifically targeted at these males.
Breast cancer is a field that has made radical advances by four concurrent strategies: identifying risk factors, using targeted population screening, producing widespread public understanding and professionwide acceptance of management guidelines. The mental health field could do likewise. Identification of risk factors and targeted screening are now possible, but coverage and compliance depend on good public understanding of mental disorders and of the importance of appropriate treatment. Understanding is poor and remedial action is required, perhaps along the lines already begun by websites such as http://www.rcpsych.ac.uk or http://www.crufad.org. The requirement of profession-wide acceptance of management guidelines seems difficult to obtain (Andrews, 1999). We would estimate that although one in five got appropriate treatment, fewer would comply and benefit. It is no wonder that the burden of mental disorders remains high.
General practitioners and specialists are overwhelmed by the thought that they should treat all people disabled by a mental disorder. If everyone did consult, practitioners indeed would be overwhelmed. But if we implemented the four strategies identified in the breast cancer literature, then the number consulting would be reduced by prevention and self-help strategies, and the number becoming chronic and needing continual help would be reduced by effective treatment. Then the burden of mental disorder might lessen, and demand and supply might balance.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSMIV). Washington, DC: APA.
Andrews, G. (1999) Randomised controlled trials
in psychiatry: important but poorly accepted. British Medical
Journal, 319,
562-564.
Andrews, G. & Henderson, S. (2000) Unmet Need in Psychiatry. Cambridge: Cambridge University Press.
Andrews, G. & Peters, L. (1998) Psychometric properties of the CIDI. Social Psychiatry and Psychiatric Epidemiology, 33, 80-88.[CrossRef][Medline]
Andrews, G., Sanderson, K., Slade, T., et al (2000) Why does the burden of disease persist? Relating the burden of anxiety and depression to effectiveness of treatment. Bulletin of the World Health Organization, 78, 446-454.[Medline]
Andrews, G., Henderson, S. & Hall, W.
(2001) Prevalence, comorbidity, disability and service
utilisation. Overview of the Australian National Mental Health Survey.
British Journal of Psychiatry,
178,
145-153.
Bebbington, P., Meltzer, H., Brugha, T., et al (2000) Unequal access and unmet need: neurotic disorders and the use of primary care services. Psychological Medicine, 30, 1359-1368.[CrossRef][Medline]
Carter, G. (1998) Service Utilisation Development for the Australian Survey of Mental Health and Wellbeing. Newcastle, NSW: University of Newcastle.
Cooper, L., Peters, L. & Andrews, G. (1998) Validity of the Composite International Diagnostic Interview (CIDI) psychosis module in a psychiatric setting. Journal of Psychiatric Research, 32, 361-368.[CrossRef][Medline]
Eysenck, S. B. G., Eysenck, H. J. & Barrett, P. A. (1985) A revised version of the psychoticism scale. Personality and Individual Differences, 6, 21-29.[CrossRef]
Gould, R. A. & Clum, G. A. (1993) A meta-analysis of self-help treatment approaches. Clinical Psychology Review, 13, 169-186.[CrossRef]
Howard, K. I., Cornille, T. A., Lyons, J. S., et al (1996) Patterns of health service utilization: special article. Archives of General Psychiatry, 53, 696-703.[Abstract]
Jablensky, A., McGrath, J., Herrman, H., et al (2000) Psychotic disorders in urban areas. Australian and New Zealand Journal of Psychiatry, 34, 221-236.[CrossRef][Medline]
Jorm, A. F. (2000) Mental health literacy.
Public knowledge and beliefs about mental disorders. British
Journal of Psychiatry, 177,
396-401.
Katz, S. J., Kessler, R. C., Frank, R. G., et al (1997) Mental health care use, morbidity and socioeconomic status in the United States and Ontario. Inquiry, 34, 38-49.[Medline]
Kessler, R. C., Brown, R. L. & Broman, C. L. (1981) Sex differences in psychiatric help seeking: evidence from four large scale surveys. Journal of Health and Social Behavior, 22, 49-64.[Medline]
Kish, L. & Frankel, M. R. (1974) Inference from complex samples. Journal of the Royal Statistical Society, Series B, 36, 1-37.
Meadows, G., Harvey, C., Fossey, E., et al (2000) Assessing perceived need for mental health care in a community survey: the development of the Perceived Need for Care Questionnaire (PNCQ). Social Psychiatry and Psychiatric Epidemiology, 35, 427-435.[CrossRef][Medline]
Murray, J. L. & Lopez, A. d. (1996) The Global Burden of Disease. Boston: World Health Organization.
Nathan, P. E. & Gorman, J. M. (1998) A Guide to Treatments That Work. Oxford: Oxford University Press.
Shah, B. V., Barnwell, B. G. & Biegler, G. S. (1997) SUDAAN User's Manual. Research Triangle Park, NC: Research Triangle Institute.
Slade, T., Peters, L., Schneiden, V., et al (1998) The International Personality Disorder Examination Questionnaire (IPDEQ): preliminary data on its utility as a screener for anxious personality disorder. International Journal of Methods in Psychiatric Research, 7, 84-88.
Ware, J. E., Kosinski, M. & Keller, S. D. (1996) A 12-item short form health survey. Medical Care, 34, 220-233.[CrossRef][Medline]
World Health Organization (2000) The World Health Report 2000. Health Systems: Improving Performance. Geneva: WHO.
Received for publication January 2, 2001. Revision received April 23, 2001. Accepted for publication April 26, 2001.
Related articles in BJP: