Health service use by adults with depression: community survey in five European countries. Evidence from the ODIN study

Sociodemographic factors and use of pain medication are associated with health-related quality of life: results from an adult community mental health service in Norway

PURPOSE

Health-related quality of life (HRQoL) is an important aspect of mental health outcomes. There are few studies on HRQoL in heterogeneous patient populations seeking help at community mental health services. The aims of the study were to compare how HRQoL, measured by the EuroQol five dimensions with five levels (EQ-5D-5L), was distributed compared to other samples from national and international studies, and to explore what factors are associated with HRQoL.

METHODS

In a cross-sectional study, 1379 Norwegian outpatients reported their HRQoL before starting treatment. Associations with demographic variables, job status, socio-economic status, and use of pain medication were examined using multiple regression analysis.

RESULTS

Most of the sample, 70% to 90%, reported problems with usual activities, pain/discomfort, and anxiety/depression; 30% to 65% reported that these problems were of a moderate to extreme degree. Forty percent reported problems with mobility, and about 20% reported problems with self-care. The sample's HRQoL was considerably lower than the general population, and comparable to patient-groups from specialist mental health services. Originating from a developing country, lower level of education, lower yearly household income, being on sick leave or unemployed, and using pain medication were associated with lower HRQoL. Age, gender, and relationship status were not associated with HRQoL. This is the first study to simultaneously examine the unique contribution of these variables in one study.

CONCLUSION

The most impacted domains of HRQoL were pain/discomfort, anxiety/depression, and usual activities. Lower HRQoL was associated with several socio-demographic factors and use of pain medication. These findings might have clinical implications and suggest that mental health professionals should routinely measure HRQoL in addition to symptom severity, to identify areas that should be targeted to improve HRQoL.

Effect of acute depression associated with COVID-19 infection on health-seeking behaviour: a psychiatrist's personal account and case report

BACKGROUND

Despite the abundant research on COVID-19-related mental health problems, little attention has been paid to acute depression occurring concurrently with the infection as a neuropsychiatric manifestation. This is important because depression is known to adversely affect help-seeking. Decreased help-seeking is likely to be aggravated by the isolation measures demanded as part of fighting the pandemic, given the disruption of social support networks.

AIMS

To study the effects of acute depression associated with COVID-19 infection on help-seeking behaviour.

METHOD

We present a case report and personal account of a patient psychiatrist who developed a first onset of acute depression as part of COVID-19 infection.

RESULTS

Despite being a mental health expert the patient lacked insight into his mood change and its negative effect on help-seeking behaviour, resulting in reliance on a family caregiver to raise the alarm.

CONCLUSIONS

For those experiencing this complex interaction between COVID-19 infection and the brain, social support will be needed to ensure timely presentation to the healthcare system. Greater attention to behavioural change as part of COVID-19 infection is needed to optimise treatment outcome.

Health Service Use among Individuals with Depression and Psychological Distress: A Population-Based Cohort Study in Ontario, Canada: Utilisation des services de santé par les personnes souffrant de dépression et de détresse psychologique : une étude de cohorte dans la population de l'Ontario, Canada

OBJECTIVES

Relatively little is known about how health-care utilization differs among individuals with psychological distress compared to those with major depressive disorder (MDD).

METHODS

Ontario participants of the Canadian Community Health Survey Cycle 1.2 (2002) were linked to health administrative data to follow their health-care utilization patterns for up to 15 years. Based on their survey responses, we classified individuals hierarchically into Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria MDD, psychological distress (Kessler-6: 8 to 24), or an unexposed group with neither condition. We compared the rates of outpatient and acute care mental and nonmental health-related visits across the 3 groups over time using Poisson regression.

RESULTS

Among the 430 individuals with MDD, 668 with psychological distress, and 9,089 in the unexposed group, individuals with MDD and psychological distress had higher rates of health-care utilization than the unexposed overall and across time. The rates of psychiatrist visits for the MDD group were significantly higher than the other groups initially but declined over the follow-up. Conversely, the rates of psychiatrist visits among the psychological distress group increased over time and converged with that of the MDD group by the end of follow-up (rate ratio_{MDD vs. psychological distress} at 1 year: 4.20 [1.97 to 11.40]; at 15 years: 1.53 [0.54 to 4.08]). Acute care visits were similar between the MDD and psychological distress groups at all time points.

CONCLUSIONS

Individuals with psychological distress required mental health care rivalling that of individuals with MDD over time, suggesting that even a cross-sectional assessment of significant psychological distress is a serious clinical concern.

Predictors of Asylum Seekers' Health Care Utilization in the Early Phase of Resettlement

BACKGROUND

Asylum seekers display high prevalence rates of posttraumatic stress disorder, depression, anxiety, and panic disorder due to pre-, peri-, and post-migration stressors. In contrast to the high mental health burden, health care utilization among asylum seekers in the early phase of resettlement is low. However, the early stages after migration are a particularly vulnerable phase in which psychosocial support measures are needed to prevent mental disorders from becoming chronic.

OBJECTIVE

To identify predictors of asylum seekers' health care utilization in the early stages of resettlement.

METHODS

Using hierarchical logistic regression analysis, the variance explanation of the (1) general utilization of health care services as well as the individual utilization of (2) outpatient psychiatrists, (3) counselling centers, and (4) general practitioners was analyzed in n = 65 asylum seekers. A structured interview on health care utilization took place between three to five months after assessment of possible predictors. We defined the following three groups of predictors a) the sociodemographic variables gender, age, number of children, religion, language proficiency, b) the psychological variables sense of coherence and emotion regulation as well as c) the asylum seekers' psychiatric diagnoses.

RESULTS

Individual sociodemographic factors, such as gender, age, and number of children as well as the emotion regulation strategy of expressive suppression and sense of coherence were shown to be predictive for the utilization of health care services among asylum seekers.

CONCLUSIONS

Low-threshold, culture-sensitive treatment offers for asylum seekers should be established in the early phase after migration. General practitioners should be a central hub for further referrals to disorder-specific treatments.

Major Depressive Disorder: Longitudinal Analysis of Impact on Clinical and Behavioral Outcomes in Uganda

BACKGROUND

There is still wide variability in HIV disease course and other HIV-related outcomes, attributable in part to psychosocial factors such as major depressive disorder (MDD), a subject that has received little attention in sub-Saharan Africa.

METHODS

Using a longitudinal cohort of 1099 HIV-positive antiretroviral therapy-naive persons, we investigated the impact of MDD on 4 HIV-related negative outcome domains in Uganda. MDD was assessed using a Diagnostic Statistical Manual IV-based tool. Also collected were data on surrogate measures of the HIV-related outcome domains. Data were collected at the 3 time points of baseline, 6, and 12 months. Multiple regression and discrete time survival models were used to investigate the relationship between MDD and indices of the HIV outcomes.

RESULTS

MDD was a significant predictor of "missed antiretroviral therapy doses" [adjusted odds ratio (aOR) = 4.75, 95% confidence interval (CI): 1.87 to 12.04, P = 0.001], "time to first visit to healthy facility" (aOR = 1.71; 95% CI: 1.07 to 2.73; P = 0.024), "time to first self-reported risky sexual activity" (aOR = 2.11, 95% CI: 1.27 to 3.49; P = 0.004) but not of "CD4 counts at months 6 and 12" (estimated effect 29.0; 95% CI: -7.8 to 65.7; P = 0.12), and "time to new WHO stage 3 or 4 clinical event" (aOR = 0.52, 95% CI: 0.12 to 2.20, P = 0.37).

CONCLUSIONS

MDD significantly impacted 3 of the 4 investigated outcome domains. These results by demonstrating the adverse consequences of an untreated mental health disorder (MDD) on HIV-related outcomes further strengthen the need to urgently act on WHO's call to integrate mental health care in general HIV care.

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

OBJECTIVE

Examine whether the severity of symptoms of depression was associated with the type of mental healthcare treatment (MHCT) received, independent of socioeconomic position (SEP).

DESIGN

Register-based 6-month follow-up study on participants from the Danish General Suburban Population Study (GESUS) 2010-2013, who scored the Major Depression Inventory (MDI).

PARTICIPANTS

Nineteen thousand and eleven respondents from GESUS.

INTERVENTIONS

The MHCT of the participants was tracked in national registers 4 months prior and 6 months after their MDI scores. MHCT was graduated in levels. SEP was defined by years of formal postsecondary education and income categorised into three levels. Data were analysed using logistic and Poisson regression analyses.

OUTCOMES

MHCT included number of contacts with: general practitioner (GP), GP mental health counselling, psychologist, psychiatrist, emergency contacts, admissions to psychiatric hospitals and prescriptions of antidepressants.

RESULTS

For 547 respondents with moderate to severe symptoms of depression there was no difference across SEP in use of services, contact (y/n), frequency of contact or level of treatment, except respondents with low SEP had more frequent contact with their GP. However, of the 547 respondents , 10% had no treatment contacts at all, and 47% had no treatment beyond GP consultation. Among respondents with no/few symptoms of depression, postsecondary education ≥3 years was associated with more contact with specialised services (adjusted OR (aOR) 1.92; 95% CI 1.18 to 3.13); however, this difference did not apply for income; additionally, high SEP was associated with fewer prescriptions of antidepressants (education aOR 0.69; CI 0.50 to 0.95; income aOR 0.56, CI 0.39 to 0.80) compared with low SEP.

CONCLUSION

Participants with symptoms of depression were treated according to the severity of their symptoms, independent of SEP; however, more than half with moderate to severe symptoms received no treatment beyond GP consultation. People in low SEP and no/few symptoms of depression were more often treated with antidepressants. The study was approved by The Danish Data Protection Agency Journal number 2015-41-3984. Accessible at: https://www.datatilsynet.dk/fortegnelsen/soeg-i-fortegnelsen/.

Major depressive disorder and suicidality in early HIV infection and its association with risk factors and negative outcomes as seen in semi-urban and rural Uganda

INTRODUCTION

There is a paucity of research into the psychiatric problems associated with early stage HIV clinical disease in sub-Saharan Africa.

METHODS

A cross sectional study was undertaken among 899 adult ART naïve persons in early stage HIV clinical disease (participants with CD4≥250 and who were at WHO clinical Stage I or II) attending a semi-urban and a rural clinic in Uganda.

RESULTS

The prevalence of major depressive disorder in this study was 14.0% [95% CI 11.7-6.3%] while that of 'moderate to high risk for suicidality' was 2.8% [95% CI 1.7%; 3.9%]. Multivariable analyses found that factors in the socio-demographic, vulnerability/protective and stress (only for major depressive disorder) domains were significantly associated with both major depressive disorder and 'moderate to high risk for suicidality'. Major depressive disorder but not 'moderate to high risk for suicidality' was significantly associated with impaired psychosocial functioning, greater utilisation of health services and non-adherence to septrin/dasone. Neither major depressive disorder nor 'moderate to high risk for suicidality' was associated with CD4 counts, risky sexual behaviour nor with non-utilisation of condoms.

LIMITATIONS

The bidirectional nature of some of the relationships between the investigated psychiatric problems, risk factors and outcomes in this cross sectional study makes it difficult to elucidate the actual direction of causality.

CONCLUSION

Early stage HIV clinical disease is associated with considerable major depressive disorder and 'moderate to high risk for suicidality'. Therefore there is a need to integrate mental health into HIV interventions that target early stage HIV disease.

Mental health service use among those with depression: an exploration using Andersen's Behavioral Model of Health Service Use

BACKGROUND

Despite positive effects on prognosis, less than half of the people diagnosed with depression access mental health services. Knowledge of what promotes such service use is limited. There is dispute about whether the receipt of mental illness related information encourages or discourages service use among those with depression. Accurate service use models are needed to inform programs designed to facilitate service use by those who would benefit most. We examine the appropriateness of Andersen's Behavioral Model of Health Service Use in this context.

METHOD

Data from 451 adults identified through the Australian National Survey of Mental Health and Wellbeing as meeting International Classification of Diseases Ten (ICD-10) criteria for depression were used.

RESULTS

Confirmatory factor analysis failed to verify Andersen's model. Thus, an empirically derived service use model was developed using exploratory factor analysis and then structural equation modelling. Mental health need was the strongest predictor of service use and the model suggested the importance of social connectedness in promoting service use. Participants who had received helpful mental illness information were significantly more likely to have accessed mental health services than those who had not.

LIMITATIONS

The cross-sectional design and lack of replication preclude definitive conclusions CONCLUSION: Andersen's model is a useful starting point for the exploration of service use among people with depression. It is necessary, however, to develop specific models for this population.

The influence of social support on healthcare service use following transport-related musculoskeletal injury

BACKGROUND

Social support has been identified as a significant factor in the recovery of individuals with musculoskeletal injury (MSI). However, relatively limited research has examined the mechanisms through which social support influences healthcare service use. This research examines the direct effects, mediating effects and effect modification of social support on healthcare service use among people with MSI sustained in a transport accident.

METHODS

The study design was secondary data analysis of cross-sectional surveys of compensated transport accident victims in Victoria in 2010 and 2011, linked to compensation claims and payment records. Analyses included (i) zero-inflated negative binomial and logistic regressions to model healthcare service use (direct effect), (ii) the Karlson, Holme and Breen (KHB) method to assess social support as a mediator of predisposing factors, need factors and healthcare service use (mediation effect), and (iii) interactions to assess social support as a modifier between predisposing factors, need factors and healthcare service use (effect modification).

RESULTS

Results of the direct analyses showed that support from family was associated with lower uptake of allied healthcare services (odds ratio (OR) 2.17; 95 % confidence intervals (CI) 1.21-3.91). Support from friends was associated with lower uptake (OR 1.87; 95 % CI 1.09-3.21) and lower rate (i.e. number of services per person) of allied healthcare services (incidence rate ratio (IRR) 0.65; 95 % CI 0.52-0.83). Support from friends (OR 0.60; 95 % CI 0.38-0.95) was also associated with lower uptake of mental healthcare services. No statistically significant mediation effects were identified for family or friends' support on the uptake of allied and mental healthcare services. Family support was found to modify the association between socio-economic indexes for areas and mental healthcare service use. In the group that reported having no social support, mental healthcare service uptake in the socioeconomically advantaged group was lower than in the disadvantaged group (OR 0.36; 95 % CI 0.16-0.83).

CONCLUSIONS

The findings suggest that social support has a direct and modifying effect on healthcare service use but does not mediate the association between predisposing factors, need factors and healthcare service use. The study findings have implications for the role of social support in the prevention, treatment and intervention of individuals with MSI.

Use of general practice services 5 years after an episode of mental illness: case-control study using electronic records

BACKGROUND

Depression, anxiety, and emotional distress occur frequently and are usually treated in general practice. Little has been reported about the long-term course of these conditions and the long-term use of medical services.

AIM

To follow up patients with depression, anxiety, and emotional distress in general practice for 5 years and examine the length and number of index episodes, prescribing behaviour, and the use of services in general practice.

DESIGN AND SETTING

A case-control study using data from electronic medical records.

METHOD

Three cohorts of patients with depression (n = 453), anxiety (n = 442), and emotional distress (n = 185) were compared against a cohort of control patients (n = 4156) during a 5-year follow-up from 2007 to 2011. The occurrence or recurrence of the index disorders, other psychological disorders or medical conditions, the numbers of prescriptions, and the number of contacts with the general practice were all examined.

RESULTS

Patients in the depression group had 1.1 followup episodes of depression, those in the anxiety group had 0.9 follow-up episodes of anxiety, and those in the emotional distress group had 0.5 follow-up episodes of emotional distress during the 5 years. All three groups had more consultations (for both psychological and somatic reasons) during each of the follow-up years than control patients. Furthermore, the groups with mental health disorders were given more prescriptions for psychopharmacological treatment.

CONCLUSION

Five years after the index episode in 2007, patients with an episode of depression, anxiety, or emotional distress are still not comparable with control patients, in terms of the prevalence of mental health conditions, the number of prescriptions, and healthcare use.

Social Support and Health Service Use in Depressed Adults: Findings From the National Health and Nutrition Examination Survey

OBJECTIVE

We investigated the relationship between social support and health service use among men and women with depression.

METHODS

Participants were 1379 adults with symptoms of depression (Patient Health Questionnaire-9 score ≥ 5) in the National Health and Nutrition Examination Survey. Using the framework of the Andersen Behavioral Model of Health Services Use, multivariable regression models used social support, stratified by depression severity, to estimate association with utilization of mental health and nonmental health services. Partial F-tests examined a priori interactions between social support and gender.

RESULTS

Among those with adequate social support, odds of seeing a nonmental health provider were much higher when depression was moderate [Odds Ratio (OR): 2.6 (1.3-5.3)] or severe [OR: 3.2 (1.2-8.7)], compared to those lacking social support. Conversely, odds of mental health service use were 60% lower among those with moderate depression [OR: 0.4 (0.2-1.0)] when social support was adequate as opposed to inadequate. Social support was unrelated to service use when depression was mild. Gender moderated the relationship between social support and health service use among individuals with severe depression.

CONCLUSIONS

Social support has opposite associations with mental and nonmental health service use among adults with clinically significant depression. This association is largely attributable to the effect of male gender on the relationship between social support and health service use.

Patterns of health care utilization related to initiation of amitriptyline, duloxetine, gabapentin, or pregabalin in fibromyalgia

Introduction

Several pharmacologic treatments are available for fibromyalgia, but little is known about the comparative effectiveness of these treatments on health care utilization.

Methods

Using US commercial insurance claims data (covering 2007 to 2009), we conducted a cohort study to examine the comparative effectiveness of amitriptyline, duloxetine, gabapentin, and pregabalin on health care utilization in patients with fibromyalgia. We measured patients’ medication adherence using the proportion of days covered (PDC) and estimated multivariable rate ratios (RRs) for outpatient visits, prescriptions, hospitalization, and emergency department (ED) visits in propensity score (PS)–matched cohorts.

Results

Cohorts of 8,269 amitriptyline, 9,941 duloxetine, and 18,613 gabapentin initiators were compared with their PS-matched pregabalin initiators. During the baseline 180-day period, patients had, on average, seven to nine physician visits, including six to eight specialist visits, and received eight prescription drugs. The mean PDC up to 180 days varied from 38.6% to 67.7%. The number of outpatient visits, prescriptions, and hospitalizations decreased slightly after initiating one of the study drugs, but the number of ED visits increased after treatment initiation. Compared to pregabalin, duloxetine was associated with decreased outpatient visits (RR, 0.94; 95% confidence interval (CI), 0.88 to 1.00), prescriptions (RR, 0.94; 95% CI, 0.90 to 0.98), hospitalizations (RR, 0.75; 95% CI, 0.68 to 0.83), and ED visits (RR, 0.85; 95% CI, 0.79 to 0.91). Little difference in health care utilization rates was noted among amitriptyline and gabapentin initiators compared to those who were started on pregabalin.

Conclusions

Fibromyalgia patients had high health care utilization before and after initiation of amitriptyline, duloxetine, gabapentin, or pregabalin. Medication adherence was suboptimal. Overall, fibromyalgia treatment had little impact on reducing health care utilization, but duloxetine initiators had less health care utilization than those started on pregabalin.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0530-8) contains supplementary material, which is available to authorized users.

Service provision for older people with mental health problems in a rural area of Australia

OBJECTIVES

Unmet mental health care needs of older people (aged 65 and over) have been identified as a serious problem internationally, particularly in rural areas. In this study we explored the views of health and social care providers of the barriers to effective mental health care for older people in a rural region in Australia.

METHOD

Semi-structured interviews were conducted with 19 participants from 13 organisations providing care and support to older people in a rural region of Australia. A framework analysis approach was used to thematically analyse the data.

RESULTS

Two main themes were identified: 'Recognising the Problem' and 'Service Availability and Access'. In particular the participants identified the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people in a rural region.

CONCLUSION

This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. The study also offers new insight into the difficulties that arise from the separation of physical and mental health systems for older people with multiple needs, and the impact of living in a rural region on unmet mental health care needs of older people.

The association between suicide and the utilization of mental health services in South Tirol, Italy: a psychological autopsy study

AIMS

The aim of the present study was to investigate potential differences between suicide decedents who had contact with a psychologist or psychiatrist before committing suicide and those individuals who had not had previous contact with a mental health professional prior to ending their lives.

METHODS

Psychological autopsy interviews (N = 396) were conducted for individuals who died by suicide between 1997 and 2007 in South Tirol, Italy.

RESULTS

The study found that suicide decedents known to mental health professionals were more frequently women and more frequently unemployed or with unstable employment. These decedents were significantly more likely than those unknown to mental health professionals to have a family history of mental illness, one or more past suicide attempts, and more frequent substance abuse, and likely to have frequent alcohol abuse. They more often had visited a physician in the last four weeks before dying and more frequently complained about psychological symptoms. In the prediction of group membership, individuals whom were known to mental health professionals prior to their suicidal act were 3 times more likely to have a family history of mental illness, 5.8 times more likely to have one past suicide attempt, 9.7 times more likely to have two or more past suicide attempts and 3.5 times more likely to have visited a physician in the four weeks prior to their death.

CONCLUSION

Our findings indicate that suicide decedents who had contact with mental health services can be distinguished from those who were not known to mental health professionals.

Social support in depression: structural and functional factors, perceived control and help-seeking

Aims. This study examined the associations of social support, loneliness and locus of control with depression and help-seeking in persons with major depression. Methods. Twelve-month help-seeking for emotional problems was assessed in a cross-sectional 2006 Estonian Health Survey. Non-institutionalized individuals aged 18-84 years (n = 6105) were interviewed. A major depressive episode was assessed using the Mini-International Neuropsychiatric Interview. Factors describing social support, social and emotional loneliness and locus of control were assessed, and their associations with depression were analysed. The associations with reported help-seeking behaviour among people identified as having a major depressive episode (n = 343) were explored. Results. Low frequency of contacts with one's friends and parents, emotional loneliness, external locus of control and emotional dissatisfaction with couple relations were significant factors predicting depression in the multivariate model. External locus of control was associated with help-seeking in the depressed sample. Interactions of emotional loneliness, locus of control and frequency of contacts with parents significantly predicted help-seeking in the depressed sample. Conclusions. Depression is associated with structural and functional factors of social support and locus of control. Help-seeking of depressed persons depends on locus of control, interactions of emotional loneliness, locus of control and contacts with the parental family.

Pharmacoeconomic analysis of paliperidone palmitate versus olanzapine pamoate for chronic schizophrenia in Norway

OBJECTIVE

Paliperidone palmitate long-acting injection (PP-LAI) has recently been approved for treatment of chronic schizophrenia. Its cost-effectiveness has not been established. The objective was to compare direct costs and outcomes between PP-LAI and olanzapine pamoate (OLZ-LAI) in treating chronic schizophrenia in Norway from the perspective of the government payer.

METHODS

We used a decision analytic model over a 1-year time horizon. Clinical inputs were derived from the literature and an expert panel; costs were taken from standard lists, adjusted to 2010 Norwegian kroner (NOK). Discounting was not done. Main outcomes included average cost per patient treated, hospitalisations, emergency room (ER) visits and quality-adjusted life years (QALYs). The pharmacoeconomic outcome was the incremental cost per QALY. Robustness was examined using one-way sensitivity analyses on critical variables and a 5000-iteration probabilistic Monte Carlo sensitivity analysis with all variables included.

RESULTS

PP-LAI generated 0.845 QALY at a cost of 151 336 NOK of which 23% was due to drugs; 25% of patients were hospitalised and another 12% required ER visits. OLZ-LAI cost 174 351 NOK (21% due to drugs); patient outcomes included 0.844 QALY, 27% hospitalisations and 14% ER visits. PP-LAI dominated OLZ-LAI in the base case. The analysis was reasonably robust against variations in drug cost but sensitive to small changes in adherence and hospitalisation rates. Overall, PP-LAI was dominant over OLZ-LAI in 54.5% of simulations. Replacing OLZ-LAI with PP-LAI would be cost saving for the Norwegian healthcare system.

CONCLUSION

PP-LAI was cost-effective compared with OLZ-LAI in treating patients with chronic schizophrenia in Norway but sensitive to changes in adherence and hospitalisation rates.

The MentDis_ICF65+ study protocol: prevalence, 1-year incidence and symptom severity of mental disorders in the elderly and their relationship to impairment, functioning (ICF) and service utilisation

BACKGROUND

The EU currently lacks reliable data on the prevalence and incidence of mental disorders in older people. Despite the availability of several national and international epidemiological studies, the size and burden of mental disorders in the elderly remain unclear due to various reasons. Therefore, the aims of the MentDis_ICF65+ study are (1) to adapt existing assessment instruments, and (2) to collect data on the prevalence, the incidence, and the natural course and prognosis of mental disorders in the elderly.

METHOD/DESIGN

Using a cross-sectional and prospective longitudinal design, this multi-centre study from six European countries and associated states (Germany, Great Britain, Israel, Italy, Spain, and Switzerland) is based on age-stratified, random samples of elderly people living in the community. The study program consists of three phases: (1) a methodological phase devoted primarily to the adaptation of age- and gender-specific assessment tools for older people (e.g., the Composite International Diagnostic Interview, CIDI) as well as psychometric evaluations including translation, back translation; (2) a baseline community study in all participating countries to assess the lifetime, 12 month and 1 month prevalence and comorbidity of mental disorders, including prior course, quality of life, health care utilization and helpseeking, impairments and participation and, (3) a 12 month follow-up of all baseline participants to monitor course and outcome as well as examine predictors.

DISCUSSION

The study is an essential step forward towards the further development and improvement of harmonised instruments for the assessment of mental disorders as well as the evaluation of activity impairment and participation in older adults. This study will also facilitate the comparison of cross-cultural results. These results will have bearing on mental health care in the EU and will offer a starting point for necessary structural changes to be initiated for mental health care policy at the level of mental health care politics.

Use of general practitioners versus mental health professionals in six European countries: the decisive role of the organization of mental health-care systems

OBJECTIVE

To investigate patterns of use of general practitioners (GPs) and/or mental health professionals (MHPs) for mental health reasons, across six European countries, and the extent to which these patterns of use are associated with differences in mental health-care delivering systems.

METHODS

Data are based on the European Study of the Epidemiology of Mental Disorders (ESEMeD): a cross-sectional survey of a representative sample of 8,796 non-institutionalized adults from six European countries, conducted between 2001 and 2003 using computer-assisted interviews with the CIDI-3.0. Countries were classified into: MHP- for countries where access to medical professionals tends to predominate (Belgium, France, Italy), and MHP+ where access to non-medical MHPs predominates (Germany, Spain, The Netherlands).

RESULTS

Among respondents consulting GPs and/or MHPs in the past year (n = 1,019), respondents from the MHP- group more often consulted GPs (68 vs. 55 % in MHP+ group), GPs and psychiatrists (23 vs. 14 %). People from the MHP+ group more often used MHPs only (45 vs. 32 %), GPs and non-medical MHPs (16 vs. 8 %). GPs from the MHP+ group were more inclined to refer patients to MHPs. Factors associated with use of GPs versus MHPs were: being over 49 years, not highly educated, lower income and suffering from mood or severe mental disorders.

CONCLUSIONS

Differences in the use of GPs versus MHPs are markedly linked to individual as well as organizational factors. Interventions are needed, in countries fostering medical access, to reimburse sessions with non-medical MHPs and improve cooperation between professionals to obtain better practice in access to care.

Decomposing differences in utilization of health services between depressed and non-depressed elders in Europe

Utilization rates of non-psychiatric health services are often higher in depressed compared to non-depressed adults. We examine whether these differences can be explained by the increased prevalence or the increased impact of demographic, socioeconomic, geographic, and health-related factors. The sample was taken from The Survey of Health, Ageing and Retirement in Europe (Wave 1 Release 2), a prospective observational study of 31,115 randomly selected people ages 50+ living in Austria, Germany, Sweden, the Netherlands, Spain, Italy, France, Denmark, Greece, Switzerland, Belgium, and Israel. Blinder-Oaxaca decomposition methods for multivariate linear regression models were used to estimate the influence of prevalence and impact of covariates on utilization among depressed and non-depressed participants. We find robust evidence that the gap in utilization between depressed and non-depressed can be accounted for by both prevalence (explained) and impact (unexplained) differences. The prevalence effect accounted for 57.7% whereas differences in the impact of covariates between depressed and non-depressed persons explained 42.3% of differences in utilization rates. Despite cross-national differences in quality and coverage of health services, in all countries, the prevalence effect was explained entirely by health measures, including: chronic diseases, functional mobility, painful symptoms, and self-reported health. The impact effect varied cross-nationally, but was largely explained by socioeconomic status and urbanicity. Hospitalization among depressed adults was twice that of non-depressed adults. Policies aimed at improving adherence and improving disease management among depressed adults should be explored.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Attitudes about depression and its treatment among mental health professionals, lay persons and immigrants and refugees in Norway

BACKGROUND

Internationally, depression is a common psychological disorder whose treatment depends upon its identification by treating professionals as well as patient utilization of mental health care systems; the latter often being hampered by cultural differences between patients and health professionals.

METHOD

The current study used vignettes of depressed patients which varied the culture and/or social circumstances of the patient to assess whether these variables influenced the conceptualization of depression and its treatment. Participants (N=722) included mental health professionals, lay people, immigrants, and refugees in Norway.

RESULTS

We found that immigrants and refugees, particularly those of non-western origin, endorsed different types of depression treatments from native Norwegians and mental health professionals, and judged who deserved treatment and who was overreacting based on the patient's culture and social circumstances, while native Norwegians did not.

LIMITATIONS

While widely used cross-culturally, vignette methodology is limited in its generalizability to real clinical situations. Acculturation was not evaluated, which may have influenced the results.

CONCLUSIONS

Findings support the integration of cultural competency ideals not only into treatment, but also into public health promotions of mental health services for lay people.

Associations of Social Relationships with Consultation for Symptoms of Depression: A Community Study of Depression in Older Men and Women in Québec

To assess associations between social relationships and consultation for symptoms of depression, data from a representative sample of 2,811 French-speaking community-dwelling older adults in Québec were used. Less than half of the older adults meeting DSM criteria for depression ( N = 379; 47.1%) had sought consultation about their depression-relevant symptoms in the preceding 12 months. Having a cohabitant partner or having children were not associated with frequency of consultation for women. Men without a partner tended to consult more frequently than men with a cohabiting partner (OR = 2.5; 95% CI = 0.81, 7.88). None of the men without a confidant had consulted. Among the 67 men with a confidant, consultation was more frequent among those not cohabiting with a partner (70%) than among those with a cohabiting partner (46%). The influence of social relationships on consultation for depression differed in men and women in this population of depressed elderly people in Québec.

General practice and mental health care: determinants of outpatient service use

OBJECTIVE

To examine the determinants that lead Canadian adults to consult family physicians, psychiatrists, psychologists, psychotherapists, and other health professionals for mental health reasons and to compare the determinants of service use across provider types.

METHOD

Data from the Canadian Community Health Survey: Mental Health and Well-Being were used for people aged 18 years and older (n = 35,236). A multivariate logistic regression was used to model outpatient consultations with different providers as a function of predictive determinants.

RESULT

Three types of variables were examined: need, enabling, and predisposing factors. Among need, the most common predictors of service use for mental health reasons were self-rated mental health, the presence of chronic conditions, depression and panic attacks, unmet mental health needs, psychological well-being, and the ability to handle daily demands. Among enabling factors, emotional and informational support and income were important predictors. Among predisposing factors, men were less likely to consult with a family physician and other resources but not with psychiatrists; and people with less education were less likely to consult psychologists and other health providers.

CONCLUSION

Need factors were the most important predictors of both psychiatrist and combined family physician and psychiatrist consultation in the previous year. However, sex barriers remain and promotion campaigns in seeking mental health care should be aimed toward men. Further, education and income barriers exist in the use of specialty providers of psychotherapy and policies should thus focus on rendering these services more accessible to disadvantaged people.

Cross-cultural equivalence of the Beck Depression Inventory: a five-country analysis from the ODIN study

BACKGROUND

The Beck Depression Inventory (BDI) has demonstrated excellent psychometric properties and good performance as a screening measure in different contexts and languages. However, comparison of its structure across countries and languages remains understudied. Measurement invariance is a prerequisite for considering the BDI equivalent across versions, and for using it to make valid and interpretable comparisons of the severity of depression among different groups.

METHODS

As part of a five-country (UK, Ireland, Spain, Norway, and Finland), two-stage epidemiological study of depressive disorder, 7934 persons were screened using the BDI. The item equivalence and measurement invariance of the BDI across the samples of the five countries was tested using Item Response Theory (IRT) and Multiple Indicators Multiple Causes (MIMIC) models.

RESULTS

Overall results support the factorial validity of the BDI, with a unidimensional structure. Item 19 (weight loss) presented a clear misfit in the five countries. IRT models, as well as MIMIC models, suggest that complete measurement invariance cannot be assumed across the five countries. The Spanish sample accounted for the majority of the differences, with a moderate to low Differential Item Functioning for the other countries on the different items.

CONCLUSIONS

The BDI could be used cross-culturally in Europe, with particular cautions regarding the Spanish sample, and with the constraints and limits pointed out for the present results. The methodology used for the present work is suggested as a soundness approach for testing the cross-cultural validity of severity rating scales.

Healthcare and preventive services utilization of elderly Europeans with depressive symptoms

BACKGROUND

Depressive symptoms are associated with increased healthcare utilization. However, it is unclear whether depressed individuals experience more or less frequent access to preventive services. Our goal was to investigate the association between depressive symptoms and both utilization of healthcare and preventive services.

METHODS

Baseline self-reported data (2004) from non-institutionalized individuals aged > or =50 years participating in the Survey of Health, Ageing, and Retirement in Europe (SHARE) were used. Of the 18,560 respondents to the baseline questionnaire, 13,580 answered the supplementary questionnaire, which included measures of preventive services. Healthcare utilization during the previous 12 months, including outpatient visits, medication, hospitalization, surgery, and home healthcare were assessed. Preventive service measures assessed the participation in influenza immunization and colorectal and breast cancer screening. Depression status was assessed with the EURO-D, a validated instrument for which a score >3 defines clinically significant depressive symptoms. Logistic regressions were performed adjusting for age, gender, socioeconomic status, behavioral risk, chronic disease, disability, and country of residence.

RESULTS

The estimated prevalence of depressive symptoms was 28.2%. Depressive symptoms were associated with significantly greater use of all healthcare domains but not preventive services, with the exception of colorectal cancer screening. Similar trends were found for each country of residence and for both genders.

LIMITATIONS

It was not known whether medical tests were used for screening or diagnostic purposes.

CONCLUSIONS

SHARE data suggest that patients with depressive symptoms are frequent users of healthcare but not preventive services. Low screening rates may reflect missed screening opportunities rather than a lack of screening opportunities.

Prevalence and predictors of health service use among Iraqi asylum seekers in the Netherlands

BACKGROUND

A long asylum procedure is associated with higher prevalence rates of psychiatric disorders, lower quality of life, higher disability and more physical health problems. Additional knowledge about health seeking behavior is necessary to guide governments and health professionals in their policies.

OBJECTIVE

To measure service use among one of the biggest asylum seekers population in the Netherlands and to assess its relationships with predisposing and need variables (including post-migration living problems).

METHOD

Two groups were randomly selected: Group 1 (n = 143), less than 6 months and Group 2 (n = 151), more than 2 years in the Netherlands. Respondents were interviewed with fully structured, culturally validated, translated questionnaires, which contained instruments to measure psychiatric disorders, quality of life, disability, physical health and post-migration living problems. Use of preventive and curative (physical and mental) health services was measured and the relationship with predisposing and need risk factors was estimated with univariate and multivariate logistic regression analyses.

RESULTS

A long asylum procedure is not associated with higher service use, except for mental health service use and drug use. Use of mental health services is, however, low compared to the prevalence of psychiatric disorders. Low quality of perceived general health and functional disability are the most important predictors of services use. Psychopathology predicts use of a medical specialist (non-psychiatrist), but does not predict mental health service use.

CONCLUSION

A high percentage of asylum seekers with a psychiatric disorder is not getting adequate treatment. There is a mismatch between the type of health problem and the type of health service use. The various health services should work together in education, detection, referral and care in order to provide help to this group of patients.

Gender differences in depressive symptoms among older adults: a cross-national comparison: the CLESA project

OBJECTIVES

To assess country-specific gender differences in depressive symptoms and to explore if exposures and vulnerabilities vary by gender among older men and women from four European countries and Israel.

METHODS

Data on 4,449 subjects between 75 and 84 years old were derived from CLESA ("Cross-national determinants of quality of life and health services for the elderly". A ratio score of depressive symptoms derived form the CESD and GDS scales was regressed on education, marital status, living arrangements, comorbidity and disability and all interactions of these factors with gender and country.

RESULTS

The prevalence of depressive symptoms is higher in women than in men in every country, except Sweden. Women are more likely to be exposed to socio-structural risks, and have poorer health and more disability than men in most of the countries. However, women are not more vulnerable to these risk factors.

CONCLUSIONS

Findings indicate that the female excess in depressive symptoms remains after taking into account the higher prevalence of socio-structural and health-related risk factors and that older women are not more vulnerable than older men to these known risk factors, suggesting the existence of additional pathways linked to gender and/or biological sex.