Socioeconomic position, symptoms of depression and subsequent mental healthcare treatment: a Danish register-based 6-month follow-up study on a population survey

Intersectional Effect of Gender, Race, and Socioeconomic Status in Mental Health Service Utilization: Evidence from the Canadian Community Health Survey 2015-2016

This study examined the intersectional effects of gender, race, and socioeconomic status (SES) on mental health service utilization (MHSU) employing the intersectionality framework. Data was extracted from Canadian Community Health Survey 2015-2016 with a total of 85,619 sample. Covariate adjusted prevalence ratio (aPR) and the predicted probability of MHSU from intersectional analyses were estimated using Poisson regression with robust variance. The prevalence of MHSU was 15.04% overall, 19.61% among women, 10.27% among men, 21.56% among white women and 11.12% among white men. The study observed overall significant intersectional effect of SES by gender and race on MHSU. For instance, white men with the lowest income were more likely to have MHSU compared to their counterparts. Similarly, the predicted probability of MHSU decreased with the increase of SES that varied by gender and race. Two-way and three-way interactions also confirmed statistical significance (p-interaction < 0.05) of intersectional effect of gender, race, and SES. The observed socioeconomic differences in MHSU across gender and racial groups can be explained by intersectionality.

Associations between psychosocial work environment factors and first-time and recurrent treatment for depression: a prospective cohort study of 24,226 employees

AIMS

Adverse factors in the psychosocial work environment are associated with the onset of depression among those without a personal history of depression. However, the evidence is sparse regarding whether adverse work factors can also play a role in depression recurrence. This study aimed to prospectively examine whether factors in the psychosocial work environment are associated with first-time and recurrent treatment for depression.

METHODS

The study included 24,226 participants from the Danish Well-being in Hospital Employees study. We measured ten individual psychosocial work factors and three theoretical constructs (effort-reward imbalance, job strain and workplace social capital). We ascertained treatment for depression through registrations of hospital contacts for depression (International Statistical Classification of Diseases and Related Health Problems version 10 [ICD-10]: F32 and F33) and redeemed prescriptions of antidepressant medication (Anatomical Therapeutic Chemical [ATC]: N06A) in Danish national registries. We estimated the associations between work factors and treatment for depression for up to 2 years after baseline among those without (first-time treatment) and with (recurrent treatment) a personal history of treatment for depression before baseline. We excluded participants registered with treatment within 6 months before baseline. In supplementary analyses, we extended this washout period to up to 2 years. We applied logistic regression analyses with adjustment for confounding.

RESULTS

Among 21,156 (87%) participants without a history of treatment for depression, 350 (1.7%) had first-time treatment during follow-up. Among the 3070 (13%) participants with treatment history, 353 (11%) had recurrent treatment during follow-up. Those with a history of depression generally reported a more adverse work environment than those without such a history. Baseline exposure to bullying (odds ratio [OR] = 1.72, 95% confidence interval [95% CI]: 1.30-2.32), and to some extent also low influence on work schedule (OR = 1.27, 95% CI: 0.97-1.66) and job strain (OR = 1.24, 95% CI: 0.97-1.57), was associated with first-time treatment for depression during follow-up. Baseline exposure to bullying (OR = 1.40, 95% CI: 1.04-1.88), lack of collaboration (OR = 1.31, 95% CI: 1.03-1.67) and low job control (OR = 1.27, 95% CI: 1.00-1.62) were associated with recurrent treatment for depression during follow-up. However, most work factors were not associated with treatment for depression. Using a 2-year washout period resulted in similar or stronger associations.

CONCLUSIONS

Depression constitutes a substantial morbidity burden in the working-age population. Specific adverse working conditions were associated with first-time and recurrent treatment for depression and improving these may contribute to reducing the onset and recurrence of depression.

Nighttime smartphone use, sleep quality, and mental health: investigating a complex relationship

STUDY OBJECTIVES

This study investigated the complex relationship between nighttime smartphone use, sleep, and mental health among adult populations in Denmark.

METHODS

Data from three interconnected samples (aged 16-89 years) from the SmartSleep Study included 5798 individuals with survey and register data; 4239 individuals also provided high-resolution smartphone tracking data. Logistic regression models and causal discovery algorithms, which suggest possible causal pathways consistent with the underlying data structure, were used to infer the relationship between self-reported and tracked nighttime smartphone use, self-reported sleep quality, mental health indicators, and register-based psychotropic medication use.

RESULTS

Frequent self-reported nighttime smartphone use was associated with high perceived stress (OR: 2.24, 95% CI = 1.42 to 3.55) and severe depressive symptoms (OR: 2.96, 95% CI = 2.04 to 4.28). We found no clear associations between tracked nighttime smartphone use and mental health outcomes, except for the cluster that used their smartphones repeatedly during the sleep period, which was associated with severe depressive symptoms (OR = 1.69, 95% CI = 1.24 to 2.31). Poor sleep quality (vs. good sleep quality) was associated with high perceived stress (OR = 5.07, 95% CI = 3.72 to 6.90), severe depressive symptoms (OR = 9.67, 95% CI = 7.09 to 13.19), and psychotropic medication use (OR = 2.13, 95% CI = 1.36 to 3.35). The causal discovery models suggest that nighttime smartphone use affects mental health through both problematic smartphone use and poor sleep quality.

CONCLUSION

The complex relationship between nighttime smartphone use, sleep, and poor mental health may create a vicious circle over time, and nighttime smartphone use may constitute a potential leverage point for public health interventions aimed at improving sleep and mental health.

Income gradient in psychotherapy use and psychotropic drug purchases: A longitudinal register study in Finnish employed population

OBJECTIVE

We examined the income gradient changes in the use of long-term rehabilitative psychotherapy and psychotropic drug purchases in men and women during a 9-year follow-up.

METHODS

We used register data from a random sample of the working-age population (18-64 years) with information on annual income, psychotherapy use and psychotropic drug purchases from 2011 to 2019 (N = 736 613, 49.7% women). Sex-stratified generalized estimating equations logistic regression models with predicted marginal probabilities were used to examine change in the treatment use rates over time for income quartiles.

RESULTS

Treatment rates increased during the follow-up, with men having lower rates than women. There were no significant differences in psychotherapy use rates between the income quartiles during the follow-up in men. A small income gradient in women (the wealthiest group with the highest use rate) remained stable throughout the follow-up. As for psychotropic drug purchases, the rates increased more among the poorest income quartile compared to the wealthiest quartile in both men and women. In the last year of the follow-up, the initial income gradient (wealthiest group having the highest psychotropic drug purchase rate) had become reversed, and the poorest group had the highest psychotropic drug purchase rate.

CONCLUSION

In psychotherapy use, no income gradient was found in men, while a stable income gradient was found in women. Psychotropic drug purchases have previously been more common in the wealthiest groups, but more recently among the poorest. The findings indicate that gender and income have distinct relationships with the treatment modality over time.

Healthcare resource utilization in patients with treatment-resistant depression—A Danish national registry study

Objectives

To investigate healthcare resource utilization (HRU) and associated costs by depression severity and year of diagnosis among patients with treatment-resistant depression (TRD) in Denmark.

Methods

Including all adult patients with a first-time hospital contact for major depressive disorder (MDD) in 1996–2015, TRD patients were defined at the second shift in depression treatment (antidepressant medicine or electroconvulsive therapy) and matched 1:2 with non-TRD patients. The risk of utilization and amount of HRU and associated costs including medicine expenses 12 months after the TRD-defining date were reported, comparing TRD patients with non-TRD MDD patients.

Results

Identifying 25,321 TRD-patients matched with 50,638 non-TRD patients, the risk of psychiatric hospitalization following TRD diagnosis was 138.4% (95%-confidence interval: 128.3–149.0) higher for TRD patients than for non-TRD MDD patients. The number of hospital bed days and emergency department (ED) visits were also higher among TRD patients, with no significant difference for somatic HRU. Among patients who incurred healthcare costs, the associated HRU costs for TRD patients were 101.9% (97.5–106.4) higher overall, and 55.2% (50.9–59.6) higher for psychiatric services than those of non-TRD patients. The relative differences in costs for TRD-patients vs non-TRD patients were greater for patients with mild depression and tended to increase over the study period (1996–2015), particularly for acute hospitalizations and ED visits.

Limitations

TRD was defined by prescription patterns besides ECT treatments.

Conclusion

TRD was associated with increased psychiatric-related HRU. Particularly the difference in acute hospitalizations and ED visits between TRD and non-TRD patients increased over the study period.

Socioeconomic differences in psychiatric treatment before and after self-harm: an observational study of 4,280 adolescents and young adults

BACKGROUND

Individuals in higher socioeconomic positions tend to utilise more mental health care, especially specialist services, than those in lower positions. Whether these disparities in treatment exist among adolescents and young adults who self-harm is currently unknown.

METHODS

The study is based on Finnish administrative register data on all individuals born 1986-1994. Adolescents and young adults with an episode of self-harm treated in specialised healthcare at ages 16-21 in 2002-2015 (n=4280, 64% female) were identified and followed 2 years before and after the episode. Probabilities of specialised psychiatric inpatient admissions and outpatient visits and purchases of psychotropic medication at different time points relative to self-harm were estimated using generalised estimation equations, multinomial models and cumulative averages. Socioeconomic differences were assessed based on parental education, controlling for income.

RESULTS

An educational gradient in specialised treatment and prescription medication was observed, with the highest probabilities of treatment among the adolescents and young adults with the highest educated parents and lowest probabilities among those whose parents had basic education. These differences emerged mostly after self-harm. The probability to not receive any treatment, either in specialised healthcare or psychotropic medication, was highest among youth whose parents had a basic level of education (before self-harm 0.39, 95% CI 0.34-0.43, and after 0.29, 95% CI 0.25-0.33 after) and lowest among youth with higher tertiary educated parents (before self-harm: 0.22, 95% CI 0.18-0.26, and after 0.18, 95% CI 0.14-0.22). The largest differences were observed in inpatient care.

CONCLUSIONS

The results suggest that specialised psychiatric care and psychotropic medication use are common among youth who self-harm, but a considerable proportion have no prior or subsequent specialised treatment. The children of parents with lower levels of education are likely to benefit from additional support in initiating and adhering to treatment after an episode of self-harm. Further research on the mechanisms underlying the educational gradient in psychiatric treatment is needed.

Risk of depression after diagnostic prostate cancer workup - A nationwide, registry-based study

OBJECTIVE

To compare the risk of depression after diagnostic workup for prostate cancer (PCa), regardless of the histopathologic outcome, with that of a cancer-free population.

METHODS

A nationwide cohort of Danish men who had a prostatic biopsy sample in 1998-2011 was identified from the Danish Prostate Cancer Registry and compared to an age-matched cohort from the background population. Men with other cancers, major psychiatric disorder, or prior use of antidepressants were excluded. The risk of depression defined as hospital contact for depression or prescription for antidepressants was determined from cumulative incidence functions and multivariate Cox regression models.

RESULTS

Of 54,766 men who underwent diagnostic workup for PCa, benign results were found for 21,418 and PCa was diagnosed in 33,347. During up to 18 years of follow-up, the adjusted hazard of depression was higher in men with PCa than in the background population, with the highest risk in the two years after diagnosis (hazard ratio (HR) 2.77, 95% CI 2.66-2.87). Comorbidity and lowest or highest income were significant risk factors for depression and the cumulative incidence was substantially higher in men with metastatic or high-risk disease. In men with benign histopathology the HR for depression was 1.22 (95% CI 1.14-1.31) in the first two years but no different from the background population after that.

CONCLUSIONS

Diagnostic workup for PCa is associated with an increased risk of depression, mainly among men with a diagnosis of PCa. Clinicians should be aware of depressive symptoms in prostate cancer patients.

GPs' drug treatment for depression by patients' educational level: registry-based study

Background

Antidepressant drugs are often prescribed in general practice. Evidence is conflicting on how patient education influences antidepressant treatment.

Aim

To investigate the association between educational attainment and drug treatment in adult patients with a new depression diagnosis, and to what extent sex and age influence the association.

Design & setting

A nationwide registry-based cohort study was undertaken in Norway from 2014–2016.

Method

The study comprised all residents of Norway born before 1996 and alive in 2015. Information was obtained on all new depression diagnoses in general practice in 2015 (primary care database) and data on all dispensed depression medication (Norwegian Prescription Database [NorPD]) 12 months after the date of diagnosis. Independent variables were education, sex, and age. Associations with drug treatment were estimated using a Cox proportional hazard model and performed separately for sex.

Results

Out of 49 967 patients with new depression (61.6% women), 15 678 were dispensed drugs (30.4% women, 33.0% men). Highly educated women were less likely to receive medication (hazard ratio [HR] = 0.93; 95% confidence interval [CI] = 0.88 to 0.98) than women with low education. No such differences appeared among men. Women aged 20–29 years were more likely to be treated with drugs than those aged 30–59 years, and women aged ≥70 years were more likely to receive drugs (HR = 1.65; 95% CI = 1.54 to 1.77) than those aged 20–29 years. The pattern was similar but less pronounced for men.

Conclusion

Educational differences in antidepressant therapy among women may reflect different treatment approaches that clinicians should be aware of to avoid unintended variation. Reasons for this variation and consequences for quality of treatment should be explored.

Use of Mental Health Services for Patients Diagnosed with Major Depressive Disorders in Primary Care

Major depressive disorder (MDD) is one of the most disabling diseases worldwide, generating high use of health services. Previous studies have shown that Mental Health Services (MHS) use is associated with patient and Family Physician (FP) factors. The aim of this study was to investigate MHS use in a naturalistic sample of MDD outpatients and the factors influencing use of services in specialized psychiatric care, to know the natural mental healthcare pathway. Non-randomized clinical trial including newly depressed Primary Care (PC) patients (n = 263) with a 12-month follow-up (from 2013 to 2015). Patient sociodemographic variables were assessed along with clinical variables (mental disorder diagnosis, severity of depression or anxiety, quality of life, disability, beliefs about illness and medication). FP (n = 53) variables were also evaluated. A multilevel logistic regression analysis was performed to assess factors associated with public or private MHS use. Subjects were clustered by FP. Having previously used MHS was associated with the use of MHS. The use of public MHS was associated with worse perception of quality of life. No other sociodemographic, clinical, nor FP variables were associated with the use of MHS. Patient self-perception is a factor that influences the use of services, in addition to having used them before. This is in line with Value-Based Healthcare, which propose to put the focus on the patient, who is the one who must define which health outcomes are relevant to him.

Socioeconomic position and mental health care use before and after first redeemed antidepressant and time until subsequent contact to psychologist or psychiatrists: a nationwide Danish follow-up study

PURPOSE

The purpose was to investigate inequalities in access to care among people with possible depression.

METHOD

In this nationwide register-based cohort study of 30,593 persons, we observed the association between socioeconomic position (SEP, education/income) and mental health care use (MHCU) four months before the date of first redeemed antidepressant (Index Date/ID) and 12 months afterwards-and time to contact to psychologist/psychiatrist (PP). Logistic, Poisson, and Cox regression models were used, adjusted for sex, age, cohabitation, and psychiatric comorbidity.

RESULTS

Before ID, high SEP was associated with less GP contact (general practitioner), higher odds ratios for GP-Mental Health Counseling (GP-MHC), psychologist contact, and admissions to hospital. This disparity decreased the following 12 months for GP-MHC but increased for contact to psychologist; same pattern was seen for rate of visits. However, the low-income group had more contact to private psychiatrist. For the 25,217 individuals with no MHCU before ID, higher educational level was associated with almost twice the rate of contact to PP the following 12 months; for the high-income group, the rate was 40% higher. 10% had contact to PP within 40 days after ID in the group with higher education; whereas, 10% of those with a short education would reach PP by day 120. High-income group had faster access as well.

CONCLUSION

Being in high SEP was positively associated with MHCU, before and after ID, and more rapid PP contact, most explicit when measured by education. Co-payment for psychologist may divert care towards private psychiatrist for low-income groups.

Factors associated with non-initiation of mental healthcare after detection of poor mental health at a scheduled health check: a cohort study

INTRODUCTION

Poor mental health is an important public health concern, but mental health problems are often under-recognised. Providing feedback to general practitioners (GPs) on their patients' mental health status may improve the identification of cases in need of mental healthcare.

OBJECTIVES

To investigate the extent of initiation of mental healthcare after identification of poor mental health and to identify factors associated with non-initiation.

DESIGN

Prospective cohort study with 1-year follow-up.

SETTING

In a population-based health preventive programme, Check Your Health, we conducted a combined mental and physical health check in Randers Municipality, Denmark, in 2012-2015 in collaboration with local GPs.

PARTICIPANTS

Participants were 350 individuals aged 30-49 years old with screen-detected poor mental health who had not received mental healthcare within the past year. The cohort was derived from 14 167 randomly selected individuals of whom 52% (n=7348) participated. Mental health was assessed by the mental component summary score of the 12-item Short-Form Health Survey.

OUTCOME

The outcome was initiation of mental healthcare. Mental healthcare included psychometric testing by GP, talk therapy by GP, contact with a psychologist, contact with a psychiatrist and psychotropic medication.

RESULTS

Within 1 year, 22% (95% CI 18 to 27) of individuals with screen-detected poor mental health initiated mental healthcare. Among individuals who initiated mental healthcare within follow-up, one in six had visited their GP once or less in the preceding year. Male sex (OR: 0.49 (95% CI 0.28 to 0.86)) and less impaired mental health (OR: 0.93 (95% CI 0.89 to 0.98)) were associated with non-initiation of mental healthcare. We found no overall association between socioeconomic factors and initiating mental healthcare.

CONCLUSION

Systematic provision of mental health test results to GPs may improve the identification of cases in need of mental healthcare, but does not translate into initiation of mental healthcare. Further research should focus on methods to improve initiation of mental healthcare, especially among men.

TRIAL REGISTRATION NUMBER

NCT02028195.

Association between over-indebtedness and antidepressant use: A cross-sectional analysis

Background

Burden of disease caused by depression and its association with socioeconomic status is well documented. However, research on over-indebtedness is scarce although millions of European citizens in all socioeconomic positions are over-indebted. Prior studies suggested that over-indebtedness is associated with poor physical and mental health.

Aims

Investigate the association between over-indebtedness and antidepressant use in Germany.

Method

A cross-sectional survey among debt advice agencies’ clients was conducted in North Rhine-Westphalia, Germany, in 2017 (OID). Data were merged with the first wave of the German Health Interview and Examination Survey for Adults (DEGS1). Descriptive statistics and logistic regression analysis were used to examine antidepressant use in the previous 7 days (OID: n = 699; DEGS1: n = 7115).

Results

Prevalence of antidepressant use was higher in the over-indebted (12.3%) than the general population (5.0%). The over-indebted were significantly more likely to use antidepressants than the general population even after controlling for other socioeconomic, demographic and health factors (adjusted odds ratio 1.83; 95% confidence interval 1.35–2.48).

Conclusions

Stakeholders in health care, debt counselling, research and social policy should consider the link between over-indebtedness and mental illness to advance the understanding of health inequalities and to help those who have mental health and debt problems.

Grief symptoms and primary care use: a prospective study of family caregivers

BACKGROUND

Family caregivers to patients who are severely ill have high use of primary health care and psychotropic medication. However, it remains sparsely investigated whether healthcare services target the most vulnerable caregivers.

AIM

This study aimed to examine associations between family caregivers' grief trajectories of persistent high-grief symptom level (high-grief trajectory) versus persistent low-grief symptom level (low-grief trajectory), as well as early contacts with GPs or psychologists and the use of psychotropic medication.

DESIGN & SETTING

A population-based cohort study of family caregivers (n = 1735) in Denmark was undertaken.

METHOD

The Prolonged Grief-13 (PG-13) scale measured family caregivers' grief symptoms at inclusion (during the patient's terminal illness), 6 months after bereavement, and 3 years after bereavement. Multinomial regression was used to analyse register-based information on GP consultations, psychologist sessions, and psychotropic medication prescriptions in the 6 months before inclusion.

RESULTS

A total of 1447 (83.4%) family caregivers contacted their GP, and 91.6% of participants in the high-grief trajectory had GP contact. Compared with family caregivers in the low-grief trajectory, family caregivers in the high-grief trajectory had ≥4 face-to-face GP consultations (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.3 to 5.0), more GP talk therapy (OR =4.4; 95% CI = 1.9 to 10.0), and more psychotropic medication, but not significantly more psychologist sessions (OR = 1.7; 95% CI = 0.5 to 6.6).

CONCLUSION

Family caregivers in the high-grief trajectory had more contact with their GP, but their persisting grief symptoms suggest that primary care interventions for family caregivers should be optimised. Future research is warranted in such interventions and in the referral patterns to specialised mental health care.