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Health Services Research Unit, Institut Municipal d’Investigació Mèdica (IMIM–Hospital del Mar), Barcelona, Spain
Fondation MGEN pour la santé publique, Université Paris 5, Paris, France
Department of Psychiatry, University of Leipzig, Germany
Division of General Medicine, University of Michigan, Ann Arbor, Michigan, USA
Research and Development Unit, Hospital Sant Joan de Deu – Serveis de Salut Mental, Barcelona, Spain
University of Bologna, Italy
Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Utrecht, The Netherlands
Department of Psychiatry, University Hospital, Gasthuisberg, Leuven, Belgium
Health Services Research Unit, Institut Municipal d’Investigació Mèdica (IMIM – Hospital del Mar), Barcelona, Spain
Assistance Publique Hopitaux de Paris, France
Department of Health Sciences, University of Leicester, UK
the ESEMeD/MHEDEA 2000 investigators
Correspondence: Jordi Alonso, Health Services Research Unit, Institut Municipal d’Investigació Mèdica (IMIM – Hospital del Mar), Carrer del Doctor Aiguader, 88 E-08003 Barcelona, Spain. Tel: + 34 93 316 0754; fax: + 34 93 316 0797; email: jalonso{at}imim.es
Declaration of interest Partial funding from GlaxoSmithKline (see Acknowledgements).
* Freely available online through the British Journal of Psychiatry
open access option. 
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Aims To estimate unmet need for mental healthcare at the population level in Europe.
Method As part of the European Study of Epidemiology of Mental Disorders (ESEMeD) project, a cross-sectional survey was conducted of representative samples of the adult general population of Belgium, France, Germany, Italy, The Netherlands and Spain (n=8796). Mental disorders were assessed with the Composite International Diagnostic Interview 3.0. Individuals with a 12-month mental disorder that was disabling or that had led to use of services in the previous 12 months were considered in need of care.
Results About six per cent of the sample was defined as being in need of mental healthcare. Nearly half (48%) of these participants reported no formal healthcare use. In contrast, only 8% of the people with diabetes had reported no use of services for their physical condition. In total, 3.1% of the adult population had an unmet need for mental healthcare. About 13% of visits to formal health services were made by individuals without any mental morbidity.
Conclusions There is a high unmet need for mental care in Europe, which may not be eliminated simply by reallocating existing healthcare resources.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Determining the need for care is a complex process (Andersen, 1995), and the ‘mere’ presence of a mental disorder may not, in fact, indicate a need for care. Some authors have suggested that it is necessary to measure not only the presence of mental disorders but also the clinical significance of those disorders in terms of their impact (Narrow et al, 2002). At the population level, need has also been defined as the population’s ability to benefit from services, rather than being a question of demand and supply (Stevens & Raftery, 1994). However, the problem with this definition is that there is no good public health indicator of the impact of treatment (Aoun et al, 2004). All of these issues complicate the definition and measurement of need for healthcare.
In this paper, we use data from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project to estimate the level of unmet need for mental healthcare from a population-based perspective. We considered there to be a need for mental healthcare only if a 12-month mental disorder had been present and it was disabling or had led to use of health services in the year prior to the interview. Our contribution to previous work is to estimate need for mental healthcare in a large and diverse sample of the general population using a feasible and conceptually sound measure of unmet need.
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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A two-stage interview procedure was used. In phase 1, respondents were screened and asked additional questions for the assessment of some mood and anxiety disorders as well as detailed questions about their use of health services, health status and main demographic characteristics. In phase 2, only individuals found to have specific mood and anxiety symptoms at phase 1 (‘high-risk’ individuals) plus a 25% random subsample of respondents without these symptoms (‘low-risk’ individuals) were asked about additional disorders, health-related information and risk factors. In this paper we present data only from respondents who completed phase 2 of the interview schedule (n=8796).
Measures
Mental disorders
We used the CIDI 3.0 (Kessler &
Ustun, 2004), a modified version of the Composite International
Diagnostic Interview (CIDI; Wittchen,
1994) to identify respondents with any of the following:
The CIDI 3.0 was developed by the World Mental Health Survey Consortium (Kessler & Ustun, 2004) and analytic algorithms for the instrument are periodically reviewed. Prevalences were estimated for the following mutually exclusive mental morbidity groups: any 12-month disorder; any lifetime disorder (but not a 12-month disorder); any lifetime sub-threshold morbidity; and no lifetime disorder (including no sub-threshold mental morbidity) (Pincus et al, 1999). In this paper the latest available version of the analytical diagnostic algorithms for the CIDI 3.0 were used (updated September 2006).
Need for mental healthcare
Individuals who reported that their mental disorder had interfered ‘a
lot’ or ‘extremely’ with their lives or their activities or
who had used formal healthcare services in the 12 months prior to the
interview for their disorder were defined as having a need for mental
healthcare services. These criteria were considered to ensure that a
conceptually sound indicator of healthcare need was used which would also be
appropriate for the general population. An approximation of the validity of
this definition was assessed by comparing the health-related quality of life,
measured by the 12-item Short Form Health Survey (SF–12;
Ware et al, 1996),
and the disability days, measured by the WHO Disability Assessment Schedule II
(DAS–II; Chwastiak et al, 2003), with the other mental
morbidity groups.
Use of health services and unmet need for mental healthcare
All respondents were asked to report their lifetime use of healthcare
services for their ‘emotions or mental health’, as well as their
use of such services in the 12 months prior to the interview. Individuals
reporting any such use of services were then asked to select whom they had
consulted from a list of formal healthcare providers (psychiatrist,
psychologist, social worker, counsellor, general family doctor or any other
medical doctor) and informal providers (e.g. religious or spiritual advisors
or other healers). For each of the providers consulted, participants were
asked about the number of visits they had made in the previous 12 months. Two
levels of health services utilisation were specified: use of any formal health
services; and visits to any mental health specialist (psychiatrist,
psychologist, social worker or counsellor). Unmet need for mental healthcare
was defined as the lack of use of any formal healthcare among individuals
defined as having a need for care. This is a low-threshold definition, since
evidence-based guidelines require a more intensive use of services to consider
that care received is appropriate (Wang
et al, 2002).
Other measures
Information on chronic physical conditions was collected for all
participants who had received the second part of the interview schedule.
Information collected included presence of the condition in the previous 12
months, the degree of interference with daily life and the number of visits to
health services because of the condition. Respondents were also asked to
complete the SF–12 and the work loss days scale of the WHO DAS–II.
The SF–12 consists of 12 items which measure eight dimensions of health
and produces a physical component summary score and mental component summary
score. The original US population weights
(Ware et al, 1996)
were used to derive the two summary measures, and the final scores were
normalised and transformed to a mean of 50 and a standard deviation of 10 for
the overall ESEMeD sample. Mean values above and below 50 represent better and
worse health status respectively compared with the general population of the
six countries studied here. The work loss days index is a self-report
instrument, measuring the proportion of days in the previous 4 weeks that an
individual was totally unable to work or carry out normal activities, or had
to cut down on the quality or quantity of work because of physical health,
mental health or use of alcohol or drugs. Scores range from 0 to 100, with
higher scores representing greater impairment.
Statistical analysis
The proportion of individuals using health services (any formal health
services or mental specialists) in the previous 12 months and the mean number
of visits per individual were estimated for each mental morbidity category.
Individuals’ data were weighted to account for the known probabilities
of selection as well as to restore age and gender distribution of the
population within countries and the relative dimension of the population
across countries (Alonso et al,
2004a).
Logistic regression analyses were carried out to assess the likelihood of not using mental healthcare in the previous 12 months. Two models were built. The dependent variable was, for the first model, unmet need (the lack of use of any formal health services) and for the second model it was the lack of use of mental specialists. Both models were restricted to individuals who needed mental healthcare in the previous 12 months. Variables included in the model were socio-demographic (age, gender, education, marital status, urbanicity, employment, income and country) and clinical (years since onset of the first mental disorder). In addition, we considered whether or not the individuals had a chronic physical condition, since this might modify the likelihood of using health services for mental reasons. The corresponding odds ratios and their 95% confidence intervals were estimated, adjusting by socio-demographic and clinical variables. We tested the interactions among all variables judged to be relevant and the adjusted odds ratios were computed when significant. Data were analysed using SAS version 8 for Windows and SUDAAN software version 8.01 was used to estimate standard errors and regression coefficients using the Taylor series linearisation method (Shah et al, 1997). Data analyses were carried out at the ESEMeD data analysis centre of the Institut Municipal d’Investigació Mèdica.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Table 2 shows that individuals defined as having a need for mental healthcare had lower mean scores on the mental component of the SF–12 than all other morbidities groups, including those with a 12-month disorder but with no need (i.e. with a non-disabling disorder) for mental healthcare (41.2 v. 45.8, respectively; P<0.01). Similar differences were found on the work loss days index (mean score of 23.4 v. 17.2 respectively; P<0.01).
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Among those defined as having a need for mental healthcare, 51.7% (95% CI 47.5–55.9) reported using any type of formal healthcare and 25.1% (95% CI 21.9–28.4) reported seeing a mental health specialist in the 12 months prior to the interview (Table 3). By combining the prevalence of need for mental health services and the proportion of those with a need for care who did not receive any formal healthcare, we estimated that 3.1% (95% CI 2.7–3.6) of the adult population had an unmet need for mental healthcare in the overall sample (Fig. 1). Across participating countries, the raw level of unmet need varied between 1.6% (95% CI 1.2–2.2) in Italy and 5.8% (95% CI 4.3–7.6) in The Netherlands.
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A total of 3447 visits to formal healthcare services were reported by those with any 12-month disorder (an average of just under 12 visits per individual), compared with 2449 visits to a specialist (approximately 17 visits per individual). More than half of all visits reported were made by individuals with a 12-month mental health need, and only 13.2% (any formal health services) and 12.9% (mental specialist) were made by individuals with no reported mental morbidity (Fig. 2).
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The first column of Table 4 shows the adjusted odds ratios of unmet need for mental healthcare (i.e. the absence of use of any formal health service among those with a need for care in the previous 12 months). Compared with the youngest age groups (18–24 years), all age groups had a substantially lower risk for unmet need (0.2 for those aged 50–64 years and those 65+, 0.3 for those aged 35–49 years and 0.5 for those aged 25–34 years; statistically significant differences). Homemakers and retired individuals had a substantial and statistically significant risk of unmet need (odds ratios 2.4 and 3.4 respectively) in comparison with those in paid employment (the reference category). Individuals whose onset of their mental disorder took place more than 15 years previously had more than twice the likelihood of unmet need for mental care. Some international variation in the level of unmet need was observed, with a higher level of unmet need in The Netherlands and a lower level of unmet need in Spain in comparison with the mean of the six countries considered. The only statistically significant interactions were found between living in Belgium and having a chronic condition, showing a protective effect on the likelihood of having unmet need for mental healthcare.
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Column 2 of Table 4 shows a similar multivariate logistic regression model, with the dependent variable being the lack of use of a mental specialist among those with a need for mental healthcare. Results were similar in overall trends but some of the previous differences were no longer statistically significant.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Estimating need for mental healthcare
The level of unmet need for mental healthcare that we have estimated for
the European general adult population is lower than previously reported values
(Regier et al, 1993;
Lin et al, 1996;
Bijl & Ravelli, 2000;
Andrews et al,
2001a; McConnell
et al, 2002; Kessler
et al, 2005). This was expected, given the more stringent
definition of need used in our study, which required the presence of
considerable level of disability and/or the use of services because of a
mental disorder. Although there is no consensus about how to measure
psychiatric disability (Work Group on
Major Depressive Disorder, 2000), our approach seems conceptually
and empirically justified, in that considerable interference with life and
activities should be considered a relevant criterion for the use of healthcare
among those with a mental disorder
(Mojtabai et al,
2002; Mechanic,
2003). In our study, contacting the health services in regard to a
mental health problem was also considered to be an indicator of the clinical
relevance of a mental health disorder
(Narrow et al, 2002).
Including individuals who had already used services in relation to their
disorder in the definition of need for care may imply some risk of
circularity, but these individuals tend to have more severe illness. Clearly
their disorder might have become less disabling owing to the treatment
received. Therefore, by definition, individuals with a 12-month disorder who
had their need for care met could not be ignored in the estimation of
need.
Increase service provision
In this study, individuals defined as having a need for mental healthcare
had substantial and statistically significant higher levels of disability and
lower quality of life than individuals with a non-disabling 12-month mental
disorder. These differences were even more noticeable in comparison with the
first group of individuals with no morbidity or sub-threshold morbidity. These
findings suggest that the measure of mental morbidity and its impact used in
this study was valid as well as being feasible for use in a large population
sample. This approach could potentially also be used to monitor the evolution
of access to mental health services. A noteworthy finding of this study is
that the utilisation of healthcare is much higher for chronic physical
conditions such as arthritis or rheumatism and diabetes than for mental
disorders. Such differences also suggest underuse of care among those with
mental disorders, in comparison with physical conditions, perhaps owing to a
lack of perception of need for care by those with mental disorders
(Mojtabai et al,
2002).
A strength of our study is that we considered other levels of mental morbidity in our analysis of the utilisation of health services (i.e. people with lifetime disorders or with sub-threshold mental morbidity). Sub-threshold depression, for instance, has been shown to be associated with an elevated risk of subsequent depression and suicidal behaviours (Andrews et al, 2001b). Taking into account additional mental health morbidity allowed us to refine the evaluation of the current use of health services for mental health reasons. In particular, we identified that only a minority (about 13%) of the visits made for mental health reasons to any formal healthcare provider were made by individuals with no mental morbidity. This suggests that even if we were able to diminish or even eliminate the probably unnecessary visits made by individuals with no mental morbidity, it would be impossible to accommodate the visits for those with unmet need for care. This is in contrast to what we had previously suggested, that reallocating current services used for psychiatric disorders might contribute substantially to diminishing the proportion of unmet need for mental healthcare (Demyttenaere et al, 2004). It is more likely that the necessary increase in use of health services for those in need of care should be obtained at the expense of more services. The participation of primary care services in general and of specialised nursing staff and/or social workers might be a viable alternative (Clarkson et al, 1999).
Limitations
Some limitations of this study deserve mention. First, the response rate in
some countries was low. The prevalence of mental disorders among
non-responders may be higher than among responders
(Graaf et al, 2000),
which might have led us to underestimate the real level of need for care.
Additionally, non-responders may use healthcare services differently from
responders. This could be particularly important in the case of France and
Belgium, which had the lowest participation rates. Similarly to other surveys,
we used self-reports to assess need for care. Although comparability of data
generated by health interviews is assured, the results might not be consistent
with other sources of information. In addition, self-reports may underestimate
health service use (Ritter et al,
2001) and thus we might have overestimated unmet need for care.
Previous work suggests that the underreporting of use of healthcare services
tends to be lower or even non-existent among those with current disorders or
those with more severe psychiatric disorders
(Rhodes et al, 2002).
On the other hand, it is more likely that we have underestimated unmet need,
for at least two reasons. First, we used a very low threshold for categorising
met need: just one visit to any formal services or to a mental health
specialist. Evidence-based recommendations of effective treatment for several
disorders including major depression (Work
Group on major Depressive Disorder, 2000), panic disorder and
agoraphobia (Lin et al,
1996) require a series of clinical visits and specific drug
treatment, well beyond the minimal approach considered in our study. This may
be a particular concern with visits to primary care providers because the
reason for the visit may be less clear. Second, we note that among our
respondents with a 12-month disorder who used health services, more than a
fifth (21.2%) had not been prescribed any active treatment
(Alonso et al,
2004b). Finally, we deliberately did not consider the
adequacy of the treatment received, which deserves specific, deeper
analyses.
Implications
The size of the treatment gap described here implies that many actions
should be taken to control mental disorders at the population level. In
addition to an increase in service provision, an increase in the access, use,
effectiveness and efficiency of existing services is necessary. This might be
achieved through improvements in the distribution of work between primary care
and specialist services, more use of shared care between primary and secondary
care, more use of best-practice tools and methods (such as clinical guidelines
and computer-assisted techniques) and continuing professional development. In
addition, other societal and attitudinal variables influence the rates of
unmet need (Andrews et al,
2001b). Educating individuals in need for mental
healthcare may be as important as expanding the services. According to our
results, the youngest patients, homemakers and retired people, as well as
those with a longer evolution of their disorder, need to be more specifically
targeted in these efforts. There is also a need for more qualitative research
to aid us in understanding why people underuse mental healthcare services.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Received for publication January 17, 2006. Revision received September 5, 2006. Accepted for publication October 27, 2006.
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