Population level of unmet need for mental healthcare in Europe

How enabling factors determine unmet healthcare needs? A panel data approach for countries

Health service need refers to the essential care required to achieve optimal health outcomes within resource constraints. When necessary services to address identified health issues are not received, unmet needs arise. This research focuses on the determinants of unmet healthcare needs across the 34 countries within the European region from 2011 to 2019, focusing on Andersen's Behavioral Model's enabling factors. We employed a static and robust panel regression model using Stata 14.0 software. Key determinants analyzed include GDP per capita, urbanization rate, and physicians per capita. Findings reveal that lower GDP per capita and lower urbanization rates are significantly correlated with higher levels of unmet healthcare needs, highlighting income level and geographical accessibility as critical factors. Additionally, a higher number of physicians per capita is associated with reduced unmet healthcare needs, indicating the importance of healthcare resources in addressing healthcare access gaps. These findings underscore the importance of targeted healthcare policies that address income level, improve healthcare accessibility, and enhance healthcare resource allocation to reduce unmet healthcare needs effectively. These findings equip policymakers and administrators with empirically grounded insights to comprehend the factors contributing to unmet healthcare needs and to develop policies aimed at addressing this challenge.

Digital assessment of cognitive-affective biases related to mental health

With an increasing societal need for digital therapy solutions for poor mental health, we face a corresponding rise in demand for scientifically validated digital contents. In this study we aimed to lay a sound scientific foundation for the development of brain-based digital therapeutics to assess and monitor cognitive effects of social and emotional bias across diverse populations and age-ranges. First, we developed three computerized cognitive tasks using animated graphics: 1) an emotional flanker task designed to test attentional bias, 2) an emotional go-no-go task to measure bias in memory and executive function, and 3) an emotional social evaluation task to measure sensitivity to social judgments. Then, we confirmed the generalizability of our results in a wide range of samples (children (N = 50), young adults (N = 172), older adults (N = 39), online young adults (N=93), and depression patients (N = 41)) using touchscreen and online computer-based tasks, and devised a spontaneous thought generation task that was strongly associated with, and therefore could potentially serve as an alternative to, self-report scales. Using PCA, we extracted five components that represented different aspects of cognitive-affective function (emotional bias, emotional sensitivity, general accuracy, and general/social attention). Next, a gamified version of the above tasks was developed to test the feasibility of digital cognitive training over a 2-week period. A pilot training study utilizing this application showed decreases in emotional bias in the training group (that were not observed in the control group), which was correlated with a reduction in anxiety symptoms. Using a 2-channel wearable EEG system, we found that frontal alpha and gamma power were associated with both emotional bias and its reduction across the 2-week training period.

Unmet need for mental health care among adolescents in Asia and Europe

The unmet need for mental health care is a global concern. There is a lack of cross-cultural studies examining adolescent help-seeking behavior from both formal and informal sources, including both high-and lower-income countries. This study investigates mental health help-seeking behavior in eight Asian and European countries. Data from 13,184 adolescents aged 13-15 (51% girls) was analysed using mixed-effects logistic regression with school-wise random intercepts to compare countries and genders. Although a significant proportion of adolescents considered getting or sought informal help, formal help-seeking remained exceptionally low, especially in middle-income countries (< 1%), while it ranged from 2 to 7% in high-income countries. Among adolescents with high emotional and behavioral problems (scoring above the 90th percentile on the Strengths and Difficulties Questionnaire), 1-2% of those in middle-income countries and 6-25% of those in high-income countries sought formal help. Girls generally seek more help than boys. The study shows the most adolescents do not receive formal help for mental health problems. The unmet need gap is enormous, especially in lower-income countries. Informal sources of support, including relatives, peers, and teachers, play a crucial role, especially in lower-income countries.

Measuring the Effect of the Early assessment Team (MEET) for patients referred to outpatient mental health care: a study protocol for a randomised controlled trial

BACKGROUND

Referrals to specialised mental health care (such as community mental health centres; CMHC) have increased over the last two decades. Patients often have multifaceted problems, which cannot only be solved by such care. Resources are limited, and triaging is challenging. A novel method which approaches patients early and individually upon referral to a CMHC-possibly with a brief intervention-is an Early assessment Team (EaT). In an EaT, two therapists meet the patient early in the process and seek to solve the present problem, often involving community services, primary health care, etc.; attention is paid to symptoms and functional strife, rather than diagnoses. This is in contrast to treatment as usual (TAU), where the patient (after being on a waiting list) meets one therapist, who focuses on history and situation to assign a diagnosis and eventually start a longitudinal treatment. The aim of this study is to describe and compare EaT and TAU regarding such outcomes as work and social adjustment, mental health, quality of life, use of health services, and patient satisfaction. The primary outcome is a change in perceived function from baseline to 12-month follow-up, measured by the Work and Social Adjustment Scale.

METHOD

Patients (18 years and above; n = 588) referred to outpatient health care at a CMHC are randomised to EaT or TAU. Measures (patient self-reports and clinician reports, patients' records, and register data) are collected at baseline, after the first and last meeting, and at 2, 4, 8, 12, and 24 months after inclusion. Some participants will be invited to participate in qualitative interviews.

TRIAL DESIGN

The study is a single-centre, non-blinded, RCT with two conditions involving a longitudinal and mixed design (quantitative and qualitative data).

DISCUSSION

This study will examine an intervention designed to determine early on which patients will benefit from parallel or other measures than assessment and treatment in CMHC and whether these will facilitate their recovery. Findings may potentially contribute to the development of the organisation of mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05087446. Registered on 21 October 2021.

Who has mental health problems? Comparing individual, social and psychiatric constructions of mental health

PURPOSE

The persistent gap between population indicators of poor mental health and the uptake of services raises questions about similarities and differences between social and medical/psychiatric constructions. Rarely do studies have assessments from different perspectives to examine whether and how lay individuals and professionals diverge.

METHODS

Data from the Person-to-Person Health Interview Study (P2P), a representative U.S. state sample (N ~ 2700) are used to examine the overlap and correlates of three diverse perspectives-self-reported mental health, a self/other problem recognition, and the CAT-MH™ a validated, computer adaptive test for psychopathology screening. Descriptive and multinominal logit analyses compare the presence of mental health problems across stakeholders and their association with respondents' sociodemographic characteristics.

RESULTS

Analyses reveal a set of socially constructed patterns. Two convergent patterns indicate whether there is (6.9%, The "Sick") or is not (64.6%, The "Well") a problem. The "Unmet Needers" (8.7%) indicates that neither respondents nor those around them recognize a problem identified by the screener. Two patterns indicate clinical need where either respondents (The "Self Deniers", 2.9%) or others (The "Network Deniers", 6.0%) do not. Patterns where the diagnostic indicator does not suggest a problem include The "Worried Well" (4.9%) where only the respondent does, The "Network Coerced" (4.6%) where only others do, and The "Prodromal" (1.4%) where both self and others do. Education, gender, race, and age are associated with social constructions of mental health problems.

CONCLUSIONS

The implications of these results hold the potential to improve our understanding of unmet need, mental health literacy, stigma, and treatment resistance.

French validation of the barriers to access to care evaluation (BACE-3) scale

BACKGROUND

The aim of this study was to develop and evaluate a French version of the Barriers to Access to Care Evaluation (BACE-3) scale that is tailored to the socio-cultural and language setting of the study.

METHODS

The translation of the BACE-3 into French and its validation were the two key components of this psychometric investigation. An online survey was created and circulated to French-speaking participants who volunteered to participate in the study.

RESULTS

For all translated questions, the reliability analysis key results (Cronbach's alpha and McDonald's Omega) were both>0.95, which is an excellent reliability value. The BACE-3 items were shown to be positively related to one another, implying excellent validity. Results of exploratory and confirmatory factor analyses showed that all stigma-related items were loaded under the same factor.

CONCLUSIONS

The BACE-3 has been validated in French, and its psychometric qualities have been thoroughly evaluated and found to be excellent.

Is there a sexual difference in the relationship between sociodemographic information and the unmet dental care needs of disabled adults? An analysis from a national survey on persons with disabilities

BACKGROUND

Health status and health care utilization in people with disabilities are more likely to be poorer than those without disabilities. Previous studies showed that there were gaps in health-related conditions by sociodemographic information and gender but the association between these factors was not explained. This study aims to analyze the relationship between sociodemographic information and the unmet dental care needs of people with disabilities and explore the effect of sex within this relationship.

METHODS

The 2014 national survey on persons with disabilities was used, which separated unmet healthcare needs into medical and dental services. Unweighted samples included 6,824 people with disabilities in total and 6,555 (96.1% of the total, weighted as 6,583) people aged 20 years or older were selected as the study population. Frequency and chi-square tests were conducted to determine differences in the prevalence of unmet dental needs based on socioeconomic information, chronic diseases, and behavioral factors after applying weights. Logistic regressions were performed using an adjusted model with sociodemographic information, chronic diseases, and behavioral variables. All analyses were performed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA).

RESULTS

Analysis of the sociodemographic factors related to unmet dental care revealed that they were higher in women and the elderly. In the fully adjusted logistic model, most of the sociodemographic information was significantly associated with unmet dental needs. The lowest group was 4.18 times more likely to have unmet dental care needs than the richest group, and females and middle-school graduates were almost twice as likely to experience unmet dental care needs than males and university graduates. Considering the interaction effect of age on unmet dental needs depending on sex differences, the odds ratio decreased for females with every annual increase in both models. Compared with the younger group, the older group showed a lower risk of having unmet dental needs, especially in females.

CONCLUSIONS

The factor most closely related to the unmet dental care needs of disabled people was socioeconomic problems. Its influence also differed by sex and age. Therefore, economic support measures and sexual differences are needed for long-term policy consideration to reduce the unmet dental care needs of disabled people.

Implementing digital mental health interventions at scale: one-year evaluation of a national digital CBT service in Ireland

BACKGROUND

In recent years, exponential growth in digital innovations and internet access has provided opportunities to deliver health services at a much greater scale than previously possible. Evidence-based technology-enabled interventions can provide cost-effective, accessible, and resource-efficient solutions for addressing mental health issues. This study evaluated the first year of a supported digital cognitive behavioral therapy (CBT) service provided by the national health service in Ireland, which has been accessible to individuals who receive a referral from one of five referring groups: General Practitioners, Primary Care Psychology, Counselling Primary Care, Community Mental Health, and Jigsaw (a nationwide youth mental health service).

METHODS

A retrospective, observational study examining data from the service between April 2021 to April 2022 was conducted. Descriptive statistics on referrals, account activations, user demographics, program usage, and user satisfaction were extracted, and pre-to-post clinical outcomes for depression measured by the Patient Health Questionnaire-9 and for anxiety measured by the Generalised Anxiety Disorder-7 were analysed using linear mixed effect models.

RESULTS

There were 5,298 referrals and 3,236 (61%) account activations within the year. Most users were female (72.9%) and aged between 18 and 44 years (75.4%). The CBT programs were associated with significant reductions in both depression (β = 3.34, 95% CI [3.03, 3.65], p < 0.001) and anxiety (β = 3.64, 95% CI [3.36, 3.93], p < 0.001), with large effect sizes (Cohen's d > 0.8). Time spent using the programs was also found to be a predictor of the variability in these clinical outcomes (p < 0.001), and accounting for this resulted in significantly better model fits (p < 0.001). User satisfaction ratings were also very high, exceeding 94%.

CONCLUSIONS

Efforts to improve the representation of male and older adult users are warranted. However, overall, the results demonstrate how digital CBT can be provided at scale and lead to symptom reductions with large effect sizes for patients seeking help for depression and anxiety. The findings substantiate the continued use and expansion of this service in Ireland and the more widespread implementation of similar services in other international public healthcare settings.

Associations between School-Behavior-Health Difficulties and Subsequent Injuries among Younger Adolescents: A Population-based Study

Objective: School-behavior-health difficulties (SBHDs) may alter physical/mental capabilities and consequently increase injury risk during daily activities. This study assessed the associations of potential SBHDs and their cumulative number (SBHDcn) with various injury types among younger adolescents. Methods: The study population included 1,559 middle-school adolescents in France (10-18 years, 98% under 16,778 boys and 781 girls). They completed a questionnaire at school-year end collecting socioeconomic features (nationality, family structure, parents' education/occupation/income), school/out-of-school injuries during the school-year (dependent variables), and SBHDs starting before the school-year (low academic performance, alcohol/tobacco/cannabis/other-illicit-drugs use, physical/verbal violence, sexual abuse, perpetrated violence, poor social support, poor general health status, sleep difficulty, depressive symptoms, and suicide attempt). Data were analyzed using logistic regression models and Kaplan-Meier estimates. Results: Injuries were frequent during school-physical/sports-training (10.9%), other-school-training (4.7%), school-free-time (7.4%), out-of-school-sports-activity (16.5%), and traffic (2.2%). Single injury (one injury all injury types combined) and ≥2 injury types affected 23.3 and 7.9% of subjects, respectively. The proportion of adolescents without SBHDs decreased with age more quickly among those with each injury type than among those without injury. Various SBHDs were associated with most injury types, single injury, and ≥2 injury types (sex-age-adjusted odds/relative-risk ratios reaching 11, p < .001). A dose-effect association was found between SBHDcn 1-2/3-5/≥6 and both single injury and ≥2 injury types (sex-age adjusted relative risk ratios reaching 12.66, p < .001, vs. SBHDcn = 0). Socioeconomic features had a moderate confounding role in these associations. Conclusions: SBHDs strongly predict injuries among adolescents. Our findings may inform healthcare providers about their prominent role in detecting/reducing SBHDs and injuries.

Building Bridges between Pharmacy and Psychosocial Care: Supporting and Referring Patients with Psychosocial Needs in a Pilot Study with Community Pharmacists

Introduction

Community pharmacists are accessible primary care providers and therefore in a good position to detect unmet psychosocial needs of their patients and pharmacy visitors.

Description

A collaboration between pharmacists and psychosocial work was set up in Flanders, Belgium. Community pharmacists were trained to discuss psychosocial needs, to inform patients about possible help and refer them to a Center for General Wellbeing if needed. During the pilot of the project between October 2021 and January 2022, the feasibility and potential of this collaboration were examined.

Discussion

A total of 79 patient contacts about psychosocial wellbeing were reported using an online registration form, the majority of which concerned women. Family problems and mental health problems were most often reported. Focus group discussions with 28 participating pharmacists showed that they experience their role in psychosocial care as fulfilling and of valuable. Patient satisfaction was mentioned to be a major motivating factor, while time and privacy are barriers. Adequate training in psychosocial wellbeing and care was considered crucial.

Conclusion

Pharmacists can be valuable partners in the recognition and referral of patients with unmet psychosocial needs. Structural collaborations between community pharmacy and psychosocial care should be further supported.

The Effectiveness of Mental Health First Aid Training among Undergraduate Students in Switzerland: A Randomized Control Trial

Half to three-fourths of mental disorders appear during adolescence or young adulthood, and the treatment gap is mainly due to lack of knowledge, lack of perceived need, and the stigmatization of mental illness. The aims of this study were to implement and evaluate a Mental Health First Aid (MHFA) training program among undergraduates. Participants were second-year students from two universities in the French-speaking region of Switzerland (N = 107), who were randomly assigned to an intervention group (n = 53) or control group (n = 54). The intervention group received a 12-h MHFA course. Online questionnaires were completed before the intervention (T0), and both 3 months (T1) and 12 months (T2) after the intervention in order to evaluate the participants' mental health knowledge, recognition of schizophrenia, and attitudes and behaviors towards mental illness. We used Generalized Estimating Equations (GEE) to examine the effects of intervention over time. After the MHFA course, the intervention group showed significantly increased basic knowledge and confidence helping others with mental illness and reduced stigmatization at both T1 and T2 compared to their baseline scores and compared to control groups. This suggests that the MHFA training program is effective and has significant short-term and long-term impacts, in terms of enhancing basic knowledge about mental health and improving attitudes towards mental illness among undergraduate students.

Mental health over the life course: Evidence for a U-shape?

Mental health problems impose substantial individual and societal costs over the life-cycle. The age-profile of mental health problems is, however, not well understood. Hence, we study the age-profile of mental health while introducing minimal bias to reach identification. Using mental health data from the United States Panel Study of Income Dynamics we apply first difference estimation to derive an unbiased estimate of the second derivative of the age effect as well as an estimate up to a linear period trend of the first derivative. Next, we use a battery of estimators with varying restrictions to approximate the first derivative. Our results suggest that the age profile of mental health in the US is not U-shaped and we find tentative evidence that the age-profile could follow an inverse U-shape where individuals experience a mental health high during their life course. Further analyses, using German and Dutch data, confirm that these results do not only apply to the US, but also to Germany and the Netherlands.

Therapist perceptions of the implementation of a new screening procedure using the ItFits-toolkit in an iCBT routine care clinic: A mixed-methods study using the consolidated framework for implementation research

Introduction

This study investigates the implementation of a new, more automated screening procedure using the ItFits-toolkit in the online clinic, Internet Psychiatry (iPsych) (www.internetpsykiatrien.dk), delivering guided iCBT for mild to moderate anxiety and depressive disorders. The study focuses on how the therapists experienced the process.

Methods

Qualitative data were collected from semi-structured individual interviews with seven therapists from iPsych. The interviews were conducted using an interview guide with questions based on the Consolidated Framework for Implementation Research (CFIR). Quantitative data on the perceived level of normalization were collected from iPsych therapists, administrative staff, and off-site professionals in contact with the target demographic at 10-time points throughout the implementation.

Results

The therapists experienced an improvement in the intake procedure. They reported having more relevant information about the patients to be used during the assessment and the treatment; they liked the new design better; there was a better alignment of expectations between patients and therapists; the patient group was generally a better fit for treatment after implementation; and more of the assessed patients were included in the program. The quantitative data support the interview data and describe a process of normalization that increases over time.

Discussion

The ItFits-toolkit appears to have been an effective mediator of the implementation process. The therapists were aided in the process of change, resulting in an enhanced ability to target the patients who can benefit from the treatment program, less expenditure of time on the wrong population, and more satisfied therapists.

Estimating demand for mental health care among Australian children and adolescents: Findings from the Young Minds Matter survey

OBJECTIVE

Mental health service use by individuals without a diagnosed mental disorder is sometimes termed 'met un-need'. However, provision of services for this group may be necessary to provide appropriate assessment, referral and early intervention. This study quantified child and adolescent use of, and perceived need for, mental health services to inform population-level service planning.

METHODS

Young people in Australia's Young Minds Matter survey (n = 5837, 5-17 years), were categorised into four 'need' groups: (1) 12-month mental disorder diagnosis; (2) remitted for more than 12 months (or experiencing a condition not surveyed); (3) 12-month subthreshold mental health problem; and (4) no indication of need for help (i.e. did not meet the requirements of the first three categories). Service demand (use of, or perceived need for, a mental health service) and number of sessions received were estimated for each, separately for children (5-11 years) and adolescents (12-17 years).

RESULTS

Some 20.1% (95% CI: [18.6, 21.7]) of children and 32.3% (95% CI: [30.5, 34.2]) of adolescents expressed a demand for mental health services in the past year. Service demand decreased across the need groups. Perceived need without service use was higher among those with a 12-month subthreshold mental health problem (13.8/20.2%) than those who had experienced a mental health problem that had remitted for more than 12 months (or were experiencing a condition not surveyed) (9.3/12.6%). In addition, 23.6% of children and 24.6% of adolescents with a demand for mental health services were classified as experiencing no indication of need for help.

CONCLUSIONS

This study quantified the number of children and adolescents in Australia who are likely to require mental health services. Findings suggest that not everyone in this group who has an expressed service demand meets diagnostic thresholds, but among those who do, service demand is higher.

Patients' and relatives' views on unmet mental health care needs through a qualitative study: Symptoms are a major barrier

Unmet needs in mental health care are a prominent issue and concern almost half of people with such disorders. Psymobile is a mobile outreach psychiatric team whose objective is to facilitate access to psychiatric services. Its intervention is at the request of relatives or social workers, making it possible to encounter situations of long-standing unmet needs. Our objective was to understand the barriers to accessing mental health care as perceived by patients and their relatives. We conducted a qualitative study with patients and their relatives using face-to-face semi-structured interviews and a hierarchical thematic analysis. Four major themes were identified: psychological and behavioural barriers, socio-economic barriers, structural barriers and physical barriers. Anosognosia or lack of insight is cited as a primary barrier, as are fear of stigma, and former negative experiences. The complexity of the French care system and the lack of literacy about mental illnesses were also emphasized by the participants. Physical determinants, such as the distance to healthcare facilities, were rarely mentioned. As a conclusion, outreach teams appear to be an appropriate way to address the issue of unmet mental health care needs when they provide psychiatric care.

Understanding differences in mental health service use by men: an intersectional analysis of routine data

PURPOSE

Rates of help-seeking for common mental health problems are lower for men, but less is known about patterns of engagement once they are in contact with services. Previous research has been limited in its ability to understand the intersection between service user characteristics and engagement. This study compared analytic approaches to investigate intersectional associations between sociodemographic and socioeconomic indicators and use of psychological treatment services by men.

METHOD

Data from 9,904 male service users attending two psychological treatment services in London were analysed. The association between ethnicity, sexual orientation, religious affiliation and employment status of service users and service use outcomes was explored using multinomial logistic regression and latent class analysis (LCA).

RESULTS

Being from a minoritised ethnic background, of Muslim faith, being unemployed, and living in the most deprived neighbourhoods were associated with greater risk of not commencing or completing treatment. Seven classes were identified in LCA, with men predominately differentiated by self-reported ethnicity and religion. Compared with the 'White British, non-religious' class, the 'Asian Muslim' class and the 'minoritised ethnic, non-religious' class were at higher risk of disengagement, whilst the 'Asian, other religion' class were at higher risk of being referred elsewhere rather than completing initiated treatment.

CONCLUSIONS

There were significant inequalities in engagement by men associated with ethnicity, religion and socioeconomic status. Compared with the regression models, further nuance was apparent in LCA regarding the intersection of gender, religion and ethnicity. Identifying groups at greater risk of discontinuation of treatment could inform more personalised pathways through care.

Explaining adults' mental health help-seeking through the lens of the theory of planned behavior: a scoping review

BACKGROUND

Despite evidence-based efficacy, mental health services are underutilized due to low rates of help-seeking, leaving unmet mental health needs a global concern. The Theory of Planned Behavior (TPB) has been applied to understand the help-seeking process and in the development of behavior change interventions. The aim of this scoping review was to map the literature on the TPB as applied to mental health help-seeking in adults aged >18 years.

METHODS

This scoping review was conducted based on the methodology presented by Arksey and O'Malley (2005). Six databases (CINAHL, PsycINFO, MEDLINE, ProQuest Health and Medicine, ProQuest Dissertations and Theses, Web of Science) and two grey literature sources (OpenGrey, Google Scholar) were systematically searched in February 2018 and updated in March 2020. Studies that explicitly discussed the TPB in the context of mental health help-seeking were initially selected; only studies that explored formal help-seeking for mental health problems and were published in English were retained. Data were extracted using Microsoft Excel.

RESULTS

Initially, 8898 records were identified. Of these, 49 met the selection criteria and were included: 32 were journal articles and 17 were theses. Forty-three papers reported on non-intervention studies and seven articles reported on TPB-based interventions. Most studies (n = 39) identified predictors of help-seeking intentions. Attitudes and perceived behavioral control were significant predictors of intentions in 35 and 34 studies, respectively. Subjective norms were a significant predictor of intentions in 23 studies. Few studies aimed to predict help-seeking behavior (n = 8). Intentions and perceived behavioral control were significant predictors of behavior in seven and six studies, respectively. Only six TPB-based interventions were identified, all used digital technology to influence help-seeking, with mixed results.

CONCLUSIONS

The present scoping review identified a considerable evidence base on the TPB for predicting mental health help-seeking intentions. Attitudes and perceived behavioral control were frequently found to be significant predictors of help-seeking intentions. Knowledge on the TPB for predicting mental health help-seeking behavior, and on TPB-based interventions, is limited. Thus, the role of the TPB in developing help-seeking interventions remains unclear. Recommendations are presented to address such research gaps and inform policy and practice.

Attitudes toward innovative mental health treatment approaches in Germany: E-mental health and home treatment

E-mental health and home treatment are treatment approaches that have proven to be effective, but are only slowly implemented in the German health care system. This paper explores the attitudes toward these innovative treatment approaches. Data was collected in two large, non-clinical samples representative of the German population in spring 2020 (N = 2,503) and winter 2020/2021 (N = 2,519). Statistical associations between variables were examined using two-tailed tests. Binary and multinomial logistic regressions were performed to predict attitudes toward online-based treatment concepts and home treatment approaches. Only few (<20%) people preferred online-based treatment approaches, while a larger proportion (~50%) could imagine being treated at home. Overall, younger subjects were more open to online-therapy approaches, while people with lower education preferred more often a traditional therapy setting. Acceptance of online-therapy did not raise significantly during the first months of the COVID-19 pandemic. When different online-based treatment options were available, the probability of accepting home treatment significantly increased with increasing levels of therapeutic support. Further promotion of acceptance for online-therapy and home treatment seems to be necessary. In the future, more information on innovative treatment approaches should be actively provided.

Clinically assessed and perceived unmet mental health needs, health care use and barriers to care for mental health problems in a Belgian general population sample

BACKGROUND

Mental health problems often remain undetected and untreated. Prior research suggests that this is mainly due to a lack of need-perception and attitudinal barriers. The aim of this study is to examine unmet mental health needs using both a clinically assessed and a self-perceived approach in a Belgian province.

METHODS

A cross-sectional survey study with a weighted representative sample of 1208 individuals aged 15 - 80 years old was carried out in 2021 in the province of Antwerp (Belgium). Mental health needs were defined as a positive symptom screening for depression (PHQ-9), anxiety (GAD-7) or alcohol abuse (AUDIT-C and CAGE), combined with experiencing significant dysfunction in daily life. Also 12-month health care use for mental health problems, self-perceived unmet mental health needs and reasons for not seeking (extra) help were assessed. Logistic regression analyses were used to explore the predictors of mental health problems, health care use, and objective and subjective unmet mental health needs.

RESULTS

One in five participants had a positive screening on one of the scales, of whom half experienced dysfunction, leading to a prevalence of 10.4% mental health needs. Among those, only half used health care for their mental health, resulting in a population prevalence of 5.5% clinically assessed unmet mental health needs. Fourteen percent of the total sample perceived an unmet mental health need. However, more women and younger people perceived unmet needs, while clinically assessed unmet needs were higher among men and older people. One in six of the total sample used health care for their mental health, most of whom did not have a clinically assessed mental health need. Motivational reasons were most often endorsed for not seeking any help, while a financial barrier was the most important reason for not seeking extra help.

CONCLUSIONS

The prevalence of unmet mental health needs is high. Assessed and perceived (unmet) mental health needs are both relevant and complementary, but are predicted by different factors. More research is needed on this discrepancy.

Usage Patterns of Telepsychology and Face-to-Face Psychotherapy: Clients' Profiles and Perceptions

Background

Currently, most people who might need mental health care services do not receive them due to a number of reasons. Many of these reasons can be overcome by telepsychology, in other words, the use of ICT technologies for therapy (e.g., phone, videoconferencing, and apps); given that it facilitates access to specialized interventions. In fact, telepsychology is currently offered as an active service in many psychotherapy centers. However, its usage, how it is perceived, and who uses it are still largely unknown.

Objective

The aim of this study was (1) to determine if any pattern exists in the usage of telepsychology and face-to-face psychology, (2) to clarify people's perception of telepsychology in terms of the advantages, barriers and efficacy of online psychotherapy, and (3) to examine usage patterns in terms of individual characteristics and identify patients' profiles.

Methods

An online survey was conducted on a convenience sample of 514 subjects recluted by using an online advertisement. The inclusion criteria were: (1) to be older than 18 years old and (2) to answer completely the questionnaire. Cluster analysis, ANOVAs, and discriminant analysis were performed to test our research objectives.

Results

Three usage clusters were found: (1) face-to-face psychotherapy (57%; n = 292); (2) non-therapy (36.8%; n = 189); and (3) combined face-to-face psychotherapy and telepsychology (6.4%; n = 33). In addition, the perception of telepsychology varied among usage clusters, but a common perception emerged about the main telepsychology advantages, barriers and efficacy. Finally, the results showed that personal characteristics differentiated people in each of these clusters.

Conclusion

The most common form of access to psychotherapy is the face-to-face form but the second way of delivery was a combination between face to face and online psychotherapy (research objective 1). People who combine face to face with online psychotherapy perceives this last as more efficient and with less barriers to access (research objective 2). Finally, some characteristic as eHealth experience and sociodemographic variables can help to identify people that will attend telepsychology initiatives (research objective 3). These clusters provide insight into opportunities for face-to-face and online patient engagement strategies.

Care pathways for people with major depressive disorder: a European Brain Council Value of Treatment study

Background

Despite well-established guidelines for managing major depressive disorder, its extensive disability burden persists. This Value of Treatment mission from the European Brain Council aimed to elucidate the nature and extent of “gaps” between best-practice and current-practice care, specifically to:Identify current treatment gaps along the care pathway and determine the extent of these gaps in comparison with the stepped-care model and Recommend policies intending to better meet patient needs (i.e., minimize treatment gaps).

Methods

After agreement upon a set of relevant treatment gaps, data pertaining to each gap were gathered and synthesized from several sources across six European countries. Subsequently, a modified Delphi approach was undertaken to attain consensus among an expert panel on proposed recommendations for minimizing treatment gaps.

Results

Four recommendations were made to increase the depression diagnosis rate (from ~50% episodes), aiming to both increase the number of patients seeking help, and the likelihood of a practitioner to correctly detect depression. These should reduce time to treatment (from ~1 to ~8 years after illness onset) and increase rates of treatment; nine further recommendations aimed to increase rates of treatment (from ~25 to ~50% of patients currently treated), mainly focused on targeting the best treatment to each patient. To improve follow-up after treatment initiation (from ~30 to ~65% followed up within 3 months), seven recommendations focused on increasing continuity of care. For those not responding, 10 recommendations focused on ensuring access to more specialist care (currently at rates of ~5–25% of patients).

Conclusions

The treatment gaps in depression care are substantial and concerning, from the proportion of people not entering care pathways to those stagnating in primary care with impairing and persistent illness. A wide range of recommendations can be made to enhance care throughout the pathway.

Economic evaluation alongside a randomized controlled trial of blended cognitive-behavioral therapy for patients suffering from major depressive disorder

OBJECTIVE

This study aimed to investigate the cost-effectiveness of blended cognitive-behavioral therapy (CBT) compared to standard CBT for adult patients suffering from major depressive disorder (MDD).

DESIGN

A cost-utility analysis alongside the randomized controlled ENTER trial.

SETTING

Center for Telepsychiatry, Mental Health Services in the Region of Southern Denmark, Denmark.

PARTICIPANTS

The study included 76 patients suffering from MDD.

INTERVENTIONS

The patients in the intervention group received blended CBT treatment comprising a combination of online modules and face-to-face consultations with a psychologist. The patients in the control group received standard CBT treatment, that is, solely face-to-face consultations with a psychologist. The treatment period was 12 weeks.

OUTCOME MEASURES

Cost-effectiveness was reported as incremental cost-effectiveness ratio. A micro-costing approach was applied to evaluate the savings derived. Changes in quality-adjusted life-years (QALYs) were estimated using the EuroQol 5-Dimensions 5-Levels questionnaire at the baseline and the six-month follow-up.

RESULTS

Data for 74 patients were included in the primary analysis. The adjusted QALY difference between blended CBT and standard CBT was -0.0291 (95% CI: -0.0535 to -0.0047), and the adjusted difference in costs was -£226.32 (95% CI: -300.86 to -151.77). Blended CBT was estimated to have a 6.6% and 3.1% probability of being cost-effective based on thresholds of £20,000 and £30,000.

CONCLUSION

Compared to standard CBT, blended CBT represents a cost-saving but also a loss in QALYs for patients suffering from MDD. However, results should be carefully interpreted, given the small sample size. Future research involving larger replication studies focusing on other aspects of blended CBT with more patient involvement is advised.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov: S-20150150.

Perceived mental illness stigma among family and friends of young people with depression and its role in help-seeking: a qualitative inquiry

BACKGROUND

Depressive disorders are a serious public health concern. Left untreated, further clinical distress and impairment in important life domains may arise. Yet, the treatment gap remains large. Prior research has shown that individuals with depressive disorders prefer seeking help from informal sources such as family and friends ahead of formal sources. However, this preference has its disadvantages such as experiencing actual, perceived and internalized stigmatizing responses from them which may delay or deter help-seeking. This paper aimed to determine the role of perceived stigma among family and friends in an individual's help-seeking behavior.

METHODS

Data were collected using semi-structured interviews with patients with depressive disorders from a tertiary psychiatric hospital in Singapore to capture individuals' self-reported experience with depression and stigmatization among family and friends. Interviews were audio recorded and transcribed verbatim. Data of 33 young adults (mean age = 26 years, SD =4.6; 18 female, 15 male) were analyzed using thematic analysis.

RESULTS

In all, four broad themes were developed: (1) absence of support, (2) provision of unhelpful support, (3) preference for non-disclosure, and (4) opposition towards formal help-seeking. Lack of awareness of depression and perpetuation of stigma manifests as barriers towards help-seeking in the form of absence of support and provision of unhelpful support which subsequently leads to a preference for non-disclosure, as well as opposition by family and friends towards formal help-seeking.

CONCLUSIONS

Data from this study can contribute to the development of public health programs aimed at improving awareness and support from family and friends and facilitating earlier help-seeking among young people with depressive disorders.

Wearable Sensing Systems for Monitoring Mental Health

Wearable systems for monitoring biological signals have opened the door to personalized healthcare and have advanced a great deal over the past decade with the development of flexible electronics, efficient energy storage, wireless data transmission, and information processing technologies. As there are cumulative understanding of mechanisms underlying the mental processes and increasing desire for lifetime mental wellbeing, various wearable sensors have been devised to monitor the mental status from physiological activities, physical movements, and biochemical profiles in body fluids. This review summarizes the recent progress in wearable healthcare monitoring systems that can be utilized in mental healthcare, especially focusing on the biochemical sensors (i.e., biomarkers associated with mental status, sensing modalities, and device materials) and discussing their promises and challenges.

Clinical Effectiveness of Blended CBT Compared vs Face-to-Face CBT for adult depression: a Randomised Controlled Non-Inferiority Trial (Preprint)

Background

Internet-based cognitive behavioral therapy (iCBT) has been demonstrated to be cost- and clinically effective. There is a need, however, for increased therapist contact for some patient groups. Combining iCBT with traditional face-to-face (FtF) consultations in a blended format may produce a new treatment format (B-CBT) with multiple benefits from both traditional CBT and iCBT, such as individual adaptation, lower costs than traditional therapy, wide geographical and temporal availability, and possibly lower threshold to implementation.

Objective

The primary aim of this study is to compare directly the clinical effectiveness of B-CBT with FtF-CBT for adult major depressive disorder.

Methods

A 2-arm randomized controlled noninferiority trial compared B-CBT for adult depression with treatment as usual (TAU). The trial was researcher blinded (unblinded for participants and clinicians). B-CBT comprised 6 sessions of FtF-CBT alternated with 6-8 web-based CBT self-help modules. TAU comprised 12 sessions of FtF-CBT. All participants were aged 18 or older and met the diagnostic criteria for major depressive disorder and were recruited via a national iCBT clinic. The primary outcome was change in depression severity on the 9-item Patient Health Questionnaire (PHQ-9). Secondary analyses included client satisfaction (8-item Client Satisfaction Questionnaire [CSQ-8]), patient expectancy (Credibility and Expectancy Questionnaire [CEQ]), and working (Working Alliance Inventory [WAI] and Technical Alliance Inventory [TAI]). The primary outcome was analyzed by a mixed effects model including all available data from baseline, weekly measures, 3-, 6, and 12-month follow-up.

Results

A total of 76 individuals were randomized, with 38 allocated to each treatment group. Age ranged from 18 to 71 years (SD 13.96) with 56 (74%) females. Attrition rate was 20% (n=15), which was less in the FtF-CBT group (n=6, 16%) than in the B-CBT group (n=9, 24%). As many as 53 (70%) completed 9 or more sessions almost equally distributed between the groups (nFtF-CBT=27, 71%; nB-CBT=26, 68%). PHQ-9 reduced 11.38 points in the FtF-CBT group and 8.10 in the B-CBT group. At 6 months, the mean difference was a mere 0.17 points. The primary analyses confirmed large and significant within-group reductions in both groups (FtF-CBT: β=–.03; standard error [SE] 0.00; P<.001 and B-CBT: β=–.02; SE 0.00; P<.001). A small but significant interaction effect was observed between groups (β=.01; SE 0.00; P=.03). Employment status influenced the outcome differently between groups, where the B-CBT group was seen to profit more from not being full-time employed than the FtF group.

Conclusions

With large within-group effects in both treatment arms, the study demonstrated feasibility of B-CBT in Denmark. At 6 months’ follow-up, there appeared to be no difference between the 2 treatment formats, with a small but nonsignificant difference at 12 months. The study seems to demonstrate that B-CBT is capable of producing treatment effects that are close to FtF-CBT and that completion rates and satisfaction rates were comparable between groups. However, the study was limited by small sample size and should be interpreted with caution.

Trial Registration

ClinicalTrials.gov NCT02796573; https://clinicaltrials.gov/ct2/show/NCT02796573

International Registered Report Identifier (IRRID)

RR2-10.1186/s12888-016-1140-y

Acceptance and Use of Telepsychology From the Clients' Perspective: Questionnaire Study to Document Perceived Advantages and Barriers

BACKGROUND

Telepsychology is increasingly being incorporated in clinical practice, being offered in many psychotherapy centers, especially after the impact of the pandemic. However, there seems to be a remarkable discrepancy between the offer, or interest in, and real-world uptake of e-mental health interventions among the population. A critical precondition is clients' willingness to accept and use telepsychology, although this issue has thus far been overlooked in research.

OBJECTIVE

The aim of this study was to examine people's acceptance and use of telepsychology by adopting an extended model of the unified theory of acceptance and use of technology (UTAUT) that integrates perceived telepsychology advantages and barriers, usefulness perceptions, behavioral intention, and telepsychology use.

METHODS

An online survey was conducted with a convenience sample of 514 participants. Structural equation models were computed to test a mediation model.

RESULTS

Results supported the UTAUT model to explain participants' acceptance and use of telepsychology. They showed a causal chain in which perceived telepsychology advantages and barriers were related to telepsychology use through the perceived usefulness of and intention to use telepsychology.

CONCLUSIONS

Telepsychology use may be explained according to the UTAUT model when coupled with participants' perceptions of telepsychology advantages and barriers. Mental health stakeholders could consider these factors in order to increase the acceptance and use of telepsychology.

Global research activity on mental health literacy

Background

Evidence showed that mental health literacy reduces stigma and promotes help-seeking intentions. This study provides a bibliometric analysis of global research activity on mental health literacy. A bibliometric method was applied using Scopus. The term “mental health literacy” was searched in the title, abstract, and author keywords for the study period from 1900 to 2019. Conventional bibliometric indicators and mapping were generated.

Results

The search query found 945 documents. The earliest documents were published in 1997. The retrieved documents received an average of 25.3 citations per document and an h-index of 67. Authors from 68 different countries participated in publishing the retrieved documents. Australia ranked first (n=354, 37.5%) followed distantly by the USA (n=172, 18.2%). In total, 362 different journals participated in publishing the retrieved documents. The Australian and New Zealand Journal of Psychiatry (n=43, 11.8%) ranked first followed by the BMC Psychiatry (n=40, 11.0%). Documents published in the BMC Psychiatry journal received the highest number (60.4) of citations per document. In total, 3906 authors participated in publishing the retrieved documents. The average number of authors per document was 4.1. Jorm, A.F ranked first (n=96, 10.2%). Data analysis indicated that the University of Melbourne (n=136, 14.1%) ranked first in the number of publications.

Conclusions

Literature on “mental health literacy” is growing rapidly mainly in high-income countries. Research collaboration between active countries and low- and middle-income countries is important since many developing countries lack expertise and the infrastructure for mental health literacy research.

Factors differentiating panic disorder with and without comorbid symptoms of depression

The aim of this study was to examine the sociodemographic and clinical differences between people with a probable diagnosis of panic disorder (PD) and those with PD and a probable comorbid diagnosis major depressive disorder (PD + MDD). We also sought to explore the potential contribution of cognitive variables to help differentiate between PD and PD + MDD. This was a subgroup analysis of 331 patients with PD symptoms who were included in the PsicAP clinical trial. All participants completed scales to evaluate panic, depression, somatization, cognitive and performance variables. A univariate analysis showed significant differences (p < .01) between the groups (PD vs PD + MDD) in clinical variables. Somatization was the best predictor of comorbid PD + MDD (β = .346; p < .01). Cognitive variables do not appear to play an essential role in predicting the presence of depressive symptoms in people with a screen positive for PD. These findings appear to support a transdiagnostic treatment approach for PD, which may be useful regardless of whether comorbid depression is present or not. PRACTITIONER POINTS: Somatic symptoms were associated with a higher probability of be in the PD + MDD group. Cognitive variables do not play a relevant role in the differentiation of both groups. A transdiagnostic approach can be useful for the treatment of PD or PD + MDD group.

Association between depressive symptoms and subsequent injuries in early adolescents: a population-based study

OBJECTIVES

Depressive symptoms (DSs) may be frequent and highly increase the risk of injuries in early adolescents (10-16 years). This study assessed the association between DSs and subsequent school and out-of-school injuries in early adolescents.

METHODS

The study population included 1219 middle-school adolescents from north-eastern France (mean age =12.7 ± 1.3) who completed at the end of school-year a questionnaire gathering socioeconomic features (nationality, family structure, parents' occupation, parents' education, and family income), obesity, alcohol use, tobacco use, health status, DSs (Kandel scale higher than the median value, hence including moderate levels), and school and out-of-school injuries during the present school-year. Were only considered the DSs and confounders that had started before the school-year. Data was analyzed using multinomial logistic regression models.

RESULTS

DSs were strongly associated with one or more school-physical/sports-training injuries (sex-age-adjusted odds ratio ORsa 2.08, p < 0.001), other-school-training injuries (ORsa 2.13, p < 0.01), school-free-time injuries (ORsa 2.84, p < 0.001), out-of-school-sports injuries (ORsa 1.95, p < 0.001), and traffic injuries (ORsa 3.78, p < 0.001). The risk was higher for having two or more injury categories (ORsa 4.03, p < 0.001) than for only one injury category (ORsa 1.80, p < 0.001). These results were robust and remained after further adjustment for socioeconomic features, obesity, alcohol use, tobacco use, and health status.

CONCLUSIONS

DSs strongly increase the injury risk in early adolescents. Injury prevention should include DSs screening and monitoring and help adolescents and their neighborhood be aware of the risk.HighlightsInjuries and depressive symptoms (DSs) are frequent in early adolescents.DSs highly predict subsequent school and out-of-school injuries and cumulating several injury types.These results are robust after adjustment for socioeconomic features, being obese, alcohol use, tobacco use and poor health status.Injury prevention should include early DSs screening and monitoring and help adolescents and their neighborhood be aware of the risk.

Mental health impact of the first wave of COVID-19 pandemic on Spanish healthcare workers: A large cross-sectional survey

INTRODUCTION

Healthcare workers are vulnerable to adverse mental health impacts of the COVID-19 pandemic. We assessed prevalence of mental disorders and associated factors during the first wave of the pandemic among healthcare professionals in Spain.

METHODS

All workers in 18 healthcare institutions (6 AACC) in Spain were invited to web-based surveys assessing individual characteristics, COVID-19 infection status and exposure, and mental health status (May 5 - September 7, 2020). We report: probable current mental disorders (Major Depressive Disorder-MDD- [PHQ-8≥10], Generalized Anxiety Disorder-GAD- [GAD-7≥10], Panic attacks, Posttraumatic Stress Disorder -PTSD- [PCL-5≥7]; and Substance Use Disorder -SUD-[CAGE-AID≥2]. Severe disability assessed by the Sheehan Disability Scale was used to identify probable "disabling" current mental disorders.

RESULTS

9,138 healthcare workers participated. Prevalence of screen-positive disorder: 28.1% MDD; 22.5% GAD, 24.0% Panic; 22.2% PTSD; and 6.2% SUD. Overall 45.7% presented any current and 14.5% any disabling current mental disorder. Workers with pre-pandemic lifetime mental disorders had almost twice the prevalence than those without. Adjusting for all other variables, odds of any disabling mental disorder were: prior lifetime disorders (TUS: OR=5.74; 95%CI 2.53-13.03; Mood: OR=3.23; 95%CI:2.27-4.60; Anxiety: OR=3.03; 95%CI:2.53-3.62); age category 18-29 years (OR=1.36; 95%CI:1.02-1.82), caring "all of the time" for COVID-19 patients (OR=5.19; 95%CI: 3.61-7.46), female gender (OR=1.58; 95%CI: 1.27-1.96) and having being in quarantine or isolated (OR= 1.60; 95CI:1.31-1.95).

CONCLUSIONS

One in seven Spanish healthcare workers screened positive for a disabling mental disorder during the first wave of the COVID-19 pandemic. Workers reporting pre-pandemic lifetime mental disorders, those frequently exposed to COVID-19 patients, infected or quarantined/isolated, female workers, and auxiliary nurses should be considered groups in need of mental health monitoring and support.

Depression treatment in Germany - using claims data to compare a collaborative mental health care program to the general practitioner program and usual care in terms of guideline adherence and need-oriented access to psychotherapy

BACKGROUND

Societies strive for fast-delivered, evidence-based and need-oriented depression treatment within budget constraints. To explore potential improvements, selective contracts can be implemented. Here, we evaluate if the German collaborative psychiatry-neurology-psychotherapy contract (PNP), which extends the gatekeeping-based general practitioner (GP) program, improved guideline adherence or need-oriented and timely access to psychotherapy compared to usual care (UC).

METHODS

We conducted a retrospective observational cohort study based on health insurance claims data. After we identified patients with depression who were on sick leave due to a mental disorder in 2015, we applied entropy balancing to adjust for selection effects and employed chi-squared tests to compare guideline adherence of the received treatment between PNP, the GP program and UC. Subsequently, we applied an extended cox regression to assess need-orientation by comparing the relationship between accumulated sick leave days and waiting times for psychotherapy across health plans.

RESULTS

N = 23,245 patients were included. Regarding guideline adherence, we found no significant differences for most severity subgroups; except that patients with a first moderate depressive episode received antidepressants or psychotherapy more often in UC. Regarding need-orientation, we observed that the effect of each additional month of sick leave on the likelihood of starting psychotherapy was increased by 6% in PNP compared to UC. Irrespective of the health plan, we found that within the first 12 months only between 24.3 and 39.7% (depending on depression severity) received at least 10 psychotherapy sessions or adequate pharmacotherapy.

CONCLUSIONS

The PNP contract strengthens the relationship between sick leave days and the delay until the beginning of psychotherapy, which suggests improvements in terms of need-oriented access to care. However, we found no indication for increased guideline adherence and - independent of the health plan - a gap in sufficient utilization of adequate treatment options.

Mental health impact of the first wave of COVID-19 pandemic on Spanish healthcare workers: A large cross-sectional survey

Introduction

Healthcare workers are vulnerable to adverse mental health impacts of the COVID-19 pandemic. We assessed prevalence of mental disorders and associated factors during the first wave of the pandemic among healthcare professionals in Spain.

Methods

All workers in 18 healthcare institutions (6 AACC) in Spain were invited to web-based surveys assessing individual characteristics, COVID-19 infection status and exposure, and mental health status (May 5 – September 7, 2020). We report: probable current mental disorders (Major Depressive Disorder-MDD- [PHQ-8≥10], Generalized Anxiety Disorder-GAD- [GAD-7≥10], Panic attacks, Posttraumatic Stress Disorder –PTSD- [PCL-5≥7]; and Substance Use Disorder –SUD-[CAGE-AID≥2]. Severe disability assessed by the Sheehan Disability Scale was used to identify probable “disabling” current mental disorders.

Results

9,138 healthcare workers participated. Prevalence of screen-positive disorder: 28.1% MDD; 22.5% GAD, 24.0% Panic; 22.2% PTSD; and 6.2% SUD. Overall 45.7% presented any current and 14.5% any disabling current mental disorder. Workers with pre-pandemic lifetime mental disorders had almost twice the prevalence than those without. Adjusting for all other variables, odds of any disabling mental disorder were: prior lifetime disorders (TUS: OR=5.74; 95%CI 2.53-13.03; Mood: OR=3.23; 95%CI:2.27-4.60; Anxiety: OR=3.03; 95%CI:2.53-3.62); age category 18-29 years (OR=1.36; 95%CI:1.02-1.82), caring “all of the time” for COVID-19 patients (OR=5.19; 95%CI: 3.61-7.46), female gender (OR=1.58; 95%CI: 1.27-1.96) and having being in quarantine or isolated (OR= 1.60; 95CI:1.31-1.95).

Conclusions

One in seven Spanish healthcare workers screened positive for a disabling mental disorder during the first wave of the COVID-19 pandemic. Workers reporting pre-pandemic lifetime mental disorders, those frequently exposed to COVID-19 patients, infected or quarantined/isolated, female workers, and auxiliary nurses should be considered groups in need of mental health monitoring and support.

Attitudinal and demographic factors associated with seeking help and receiving antidepressant medication for symptoms of common mental disorder

BACKGROUND

Despite the increased attention given to improvement of mental health-related knowledge and attitudes, rates of help-seeking for mental illness remain low even in countries with well-developed mental health services. This study examines the relationships between attitudes to mental illness, symptoms of common mental disorder and seeking-help and receiving medication for a mental health problem.

METHODS

We used data from the nationally representative Health Survey for England 2014 to design three logistic regression models to test for the effects of attitudes to mental illness (measured by a shortened version of the Community Attitudes toward the Mentally Ill, CAMI scale) on: recent contact with a doctor for a mental health problem; use of any type of mental health service in the last 12 months; and having antidepressants currently prescribed, while controlling for symptoms of common mental disorder (measured by the General Health Questionnaire, GHQ). We also tested for an interaction between attitudes to mental illness and symptoms of common mental disorder on the outcomes.

RESULTS

A significant but very small effect of CAMI score was found on 'antidepressants currently prescribed' model (OR = 1.01(1.00, 1.02) but not on the two indicators of help-seeking. We also found a significant but very small interaction between CAMI and GHQ scores on recent contact with a doctor (OR = 0.99, 95% CI (0.990, 0.998); adjusted Wald test P = 0.01)). Knowing someone with a mental illness had a significant positive effect on help-seeking indicated by: (a) recent contact with a doctor (2.65 (1.01, 6.98)) and (b) currently prescribed antidepressant (2.67 (1.9, 3.75)) after controlling for attitudes to mental illness.

CONCLUSIONS

Our results suggest that knowing someone with a mental health problem seems to have a further positive effect on help-seeking, beyond improving attitudes to mental illness. Furthermore, multiple different types and aspects of stigma may contribute to help-seeking behaviours, consequently multi-faceted approaches are likely to be most efficient.

Global Mental Health and Services for Migrants in Primary Care Settings in High-Income Countries: A Scoping Review

Migrants are at a higher risk for common mental health problems than the general population but are less likely to seek care. To improve access, the World Health Organization (WHO) recommends the integration of mental health services into primary care. This scoping review aims to provide an overview of the types and characteristics of mental health services provided to migrants in primary care following resettlement in high-income countries. We systematically searched MEDLINE, EMBASE, PsycInfo, Global Health, and other databases from 1 January 2000 to 15 April 2020. The inclusion criteria consisted of all studies published in English, reporting mental health services and practices for refugee, asylum seeker, or undocumented migrant populations, and were conducted in primary care following resettlement in high-income countries. The search identified 1627 citations and we included 19 studies. The majority of the included studies were conducted in North America. Two randomized controlled trials (RCTs) assessed technology-assisted mental health screening, and one assessed integrating intensive psychotherapy and case management in primary care. There was a paucity of studies considering gender, children, seniors, and in European settings. More equity-focused research is required to improve primary mental health care in the context of global mental health.

Shame in a post-socialist society: a qualitative study of healthcare seeking and utilisation in common mental disorders

After the regime collapse, the former socialist societies in Central and Eastern Europe experienced rapid social and economic transformations. Consequently, mental health deterioration coupled with ambitions to break with the past triggered reforms of mental health systems. Yet, 30 years later, mental health in the region remains poor. Stigma of mental illness may be one of the factors that delays help seeking and, therefore, maintains status quo. Thus, the aim of the article is to better understand the roots of stigma and the process of stigmatisation in one of these countries - Lithuania. Drawing on Norbert Elias's model of established-outsider relations, the article presents the analysis of 23 in-depth interviews with healthcare providers and users of services diagnosed with depression or anxiety disorders. Said analysis reveals how stigma of mental illness might result in damaged self-image and shame of feeling different. Mental illness and healthcare seeking are perceived as a threat to culturally and historically determined self-values, at the core of which seems to be intolerance of difference. The article contributes not only to research concerning mental health in a relatively understudied region of Central and Eastern Europe, but also to existing literature on stigma as embedded in a local context.

Mind the treatment gap: the prevalence of common mental disorder symptoms, risky substance use and service utilization among young Swiss adults

Background

Common mental disorders (CMDs) are highly prevalent and contribute significantly to the global burden of disease, yet there is evidence of a large treatment gap. We aimed to quantify this gap among young adults with symptoms of CMDs and examine the relationship between substance use and perceived need for care and mental health service utilization.

Methods

In a nationally representative, cross-sectional survey of young Swiss adults’ mental health and wellbeing, we assessed symptoms of anxiety, depression, and attention deficit hyperactivity disorder (ADHD) with widely used screening instruments and asked about participant suicidal ideation, suicide attempts, mental health-related quality of life, alcohol and drug use, perceived need for mental health care, and mental health service utilization. We used these variables to calculate the treatment gap and weighted all analyses according to the stratified sampling plan.

Results

Around a quarter of young adults screened positive for at least one CMD. Participants who screened positive for anxiety and/or depression reported significantly more suicidal ideation and lifetime suicide attempts and reported worse mental health-related quality of life than participants who did not screen positive for a disorder. Women’s prevalence of anxiety and depression symptoms was significantly higher than men’s, while men were more likely to report most types of risky drug use. Among those with a CMD, only around half perceived lifetime need for care, and less than 20% reported currently utilizing mental health services. Young adults with a CMD reporting risky weekly use of alcohol were less likely to be currently using services.

Conclusion

The high prevalence of CMD symptoms could reflect a rising prevalence of these disorders mirroring increasing trends observed in other countries. To address the large treatment gap, interventions promoting mental health literacy and more research on additional barriers to inform further interventions are needed.

Unmet mental health needs in the general population: perspectives of Belgian health and social care professionals

Background

An unmet mental health need exists when someone has a mental health problem but doesn’t receive formal care, or when the care received is insufficient or inadequate. Epidemiological research has identified both structural and attitudinal barriers to care which lead to unmet mental health needs, but reviewed literature has shown gaps in qualitative research on unmet mental health needs. This study aimed to explore unmet mental health needs in the general population from the perspective of professionals working with vulnerable groups.

Methods

Four focus group discussions and two interviews with 34 participants were conducted from October 2019 to January 2020. Participants’ professional backgrounds encompassed social work, mental health care and primary care in one rural and one urban primary care zone in Antwerp, Belgium. A topic guide was used to prompt discussions about which groups have high unmet mental health needs and why. Transcripts were coded using thematic analysis.

Results

Five themes emerged, which are subdivided in several subthemes: (1) socio-demographic determinants and disorder characteristics associated with unmet mental health needs; (2) demand-side barriers; (3) supply-side barriers; (4) consequences of unmet mental health needs; and (5) suggested improvements for meeting unmet mental health needs.

Conclusions

Findings of epidemiological research were largely corroborated. Some additional groups with high unmet needs were identified. Professionals argued that they are often confronted with cases which are too complex for regular psychiatric care and highlighted the problem of care avoidance. Important system-level factors include waiting times of subsidized services and cost of non-subsidized services. Feelings of burden and powerlessness are common among professionals who are often confronted with unmet needs. Professionals discussed future directions for an equitable mental health care provision, which should be accessible and targeted at those in the greatest need. Further research is needed to include the patients’ perspective of unmet mental health needs.

How expensive are post-traumatic stress disorders? Estimating incremental health care and economic costs on anonymised claims data

BACKGROUND

Post-traumatic stress disorders (PTSD) pose a high burden for individuals and societies. Although prevalence rates are rather low, high co-occurrence rates and overall impairments cause deleterious suffering and significant costs. Still, no long-term data on costs and trends in cost developments are available.

METHODS

Claims data from a German research database were analysed regarding direct and indirect costs occurring for individuals with incident diagnoses of PTSD. Results were compared to non-exposed average insurants matched on age and gender. Costs were analysed over a 5-year period from 2 years preceding until 3 years following an incident diagnosis of PTSD.

RESULTS

Overall costs for PTSD account for approximately 43,000 EUR per individual, which is three times higher than costs for non-exposed controls. Of these costs, 59% are caused by mental disorders, 18% specifically by PTSD. In the control group, costs for mental disorders account for 19% of total costs. Costs increase by 142% in the year after an incident diagnosis of PTSD but return to the initial level 2 years later. Still, costs are at least twice as high in every year as in those for the comparison group.

CONCLUSIONS

Individuals with PTSD seem to suffer from far more impairments in their general health conditions and incur many more costs than average insurants. Most of these seem to be caused by co-occurring mental disorders and show their maximum in the index year. Nevertheless, as costs decrease to their initial level, treatments seem to have counterbalanced the impairments due to PTSD. Thus, treatments for PTSD can be considered as beneficial and their cost-effectiveness should be further investigated.

How does the integration of collaborative care elements in a gatekeeping system affect the costs for mental health care in Germany?

Mental disorders are widespread, debilitating and associated with high costs. In Germany, usual care (UC) for mental disorders is afflicted by poor coordination between providers and long waiting times. Recently, the primary alternative to UC-the gatekeeping-based general practitioners (GP) program-was extended by the collaborative Psychiatry-Neurology-Psychotherapy (PNP) program, which is a selective contract designed to improve mental health care and the allocation of resources. Here, we assess the effects of the GP program and the PNP program on costs for mental health care. We analyzed claims data from 2014 to 2016 of 55,472 adults with a disorder addressed by PNP to compare costs and sick leave days between PNP, the GP program and UC. The individuals were grouped and balanced via entropy balancing to adjust for potentially confounding covariates. We employed a negative binomial model to compare sick leave days and two-part models to compare sick pay, outpatient, inpatient and medication costs over a 12-month period. The PNP program significantly reduced sick pay by 164€, compared to UC, and by 177€, compared to the GP program. Consistently, sick leave days were lower in PNP. We found lower inpatient costs in PNP than in UC (-194€) and in the GP program (-177€), but no reduction in those shares of inpatient costs that accrued in psychiatric or neurological departments. Our results suggest that integrating collaborative care elements in a gatekeeping system can favourably impact costs. In contrast, we found no evidence that the widely implemented GP program reduces costs for mental health care.

Lived experiences: a focus group pilot study within the MentALLY project of mental healthcare among European users

BACKGROUND

Mental healthcare is an important component in societies' response to mental health problems. Although the World Health Organization highlights availability, accessibility, acceptability and quality of healthcare as important cornerstones, many Europeans lack access to mental healthcare of high quality. Qualitative studies exploring mental healthcare from the perspective of people with lived experiences would add to previous research and knowledge by enabling in-depth understanding of mental healthcare users, which may be of significance for the development of mental healthcare. Therefore, the aim of the current study was to describe experiences of mental healthcare among adult Europeans with mental health problems.

METHOD

In total, 50 participants with experiences of various mental health problems were recruited for separate focus group interviews in each country. They had experiences from both the private and public sectors, and with in- and outpatient mental healthcare. The focus group interviews (N = 7) were audio recorded, transcribed verbatim and analysed through thematic analysis. The analysis yielded five themes and 13 subthemes.

RESULTS

The theme Seeking and trying to find help contained three subthemes describing personal thresholds for seeking professional help, not knowing where to get help, and the importance of receiving help promptly. The theme Awaiting assessment and treatment contained two subthemes including feelings of being prioritized or not and feelings of being abandoned during the often-lengthy referral process. The theme Treatment: a plan with individual parts contained three subthemes consisting of demands for tailored treatment plans in combination with medications and human resources and agreement on treatment. The theme Continuous and respectful care relationship contained two subthemes describing the importance of continuous care relationships characterised by empathy and respect. The theme Suggestions for improvements contained three subthemes highlighting an urge to facilitate care contacts and to increase awareness of mental health problems and a wish to be seen as an individual with potential.

CONCLUSION

Facilitating contacts with mental healthcare, a steady contact during the referral process, tailored treatment and empathy and respect are important aspects in efforts to improve mental healthcare. Recommendations included development of collaborative practices between stakeholders in order to increase general societal awareness of mental health problems.

Patients' preferences for the treatment of anxiety and depressive disorders: a systematic review of discrete choice experiments

Introduction: Matching available mental health services to patients' preferences, as well as is possible, may increase patient satisfaction and help increase adherence to certain treatments. This study systematically reviewed discrete-choice experiments (DCEs) on patients' preferences for treatment of depressive and anxiety disorders and assessed the relative importance of outcome, process and cost attributes to improve the current and future treatment situations.Methods: A systematic literature review using PubMed, EMBASE and PsychInfo was conducted to retrieve all relevant DCEs published up to 15 April 2019, eliciting patient preferences for treatment of depressive and anxiety disorders. Data were extracted using an extraction sheet, and attributes were classified into outcome, process and cost attributes. The relative importance of each attribute category was then assessed, and studies were evaluated according to their reporting quality, using validated checklists.Results: A total of 11 studies were identified for qualitative analysis. All studies received an aggregate score of 4 on the five-point PREFS checklist (Purpose, Respondents, Explanation, Findings and Significance). Most attributes were outcome related (52%), followed by process (42%) and cost (6%) attributes. Comparing the attribute categories and summing up the relative importance weights for each category within the studies, process attributes were ranked as most important, followed by cost and outcome attributes.Conclusions: In this systematic review, heterogeneous results were observed regarding the inclusion and framing of different attributes across studies. Overall, patients considered process and cost attributes to be more important than outcome attributes. Outcomes and process are important for patients, and thus clinicians should be particularly aware of this and take patients' preferences into account, although the attribute importance may depend on chosen attributes and related levels.

Experiences and implications of smartphone apps for depression and anxiety

Apps on smartphones are increasingly used for self-care for depression and anxiety, yet how and why they are accessed, and their social effects, remain under-investigated. Sociologists have begun to theorise how these technologies affect and relate; crucial questions for a contemporary sociology of health. This study seeks to contribute to our conceptualisation of how digital health technologies are implicated in health by investigating the motivations, experiences and relations of people using mobile apps for depression or anxiety. We interviewed 14 individuals living in England with a diagnosis of depression or an anxiety disorder, who used smartphone apps as part of self-care. Analysis followed a thematic approach. Three themes were identified. Apps exist within relational contexts - alongside smartphones, beliefs about mental health and other support - which shape app use and lead to an imprecise, casual approach. People engage with apps in a straightforward and uncomplicated manner, leading to immediate symptomatic alleviation, but to limited longer term benefit. The contradiction between the apps' promise as tools of individual empowerment, with their ability to promote responsibilising frameworks that restrain users' reflexivity, is central to their implications. Apps can thus contribute to isolation from interpersonal support and promote reductionist biomedical conceptualisations of mental ill health.

EPA guidance on the quality of mental health services

The main aim of this guidance of the European Psychiatric Association is to provide evidence-based recommendations on the quality of mental health services in Europe. The recommendations were derived from a systematic search of the best available evidence in the scientific literature, supplemented by information from documents retrieved upon reviewing the identified articles. While most recommendations could be based on empirical studies (although of varying quality), some had to be based on expert opinion alone, but were deemed necessary as well. Another limitation was that the wide variety of service models and service traditions for the mentally ill worldwide often made generalisations difficult. In spite of these limitations, we arrived at 30 recommendations covering structure, process and outcome quality both on a generic and a setting-specific level. Operationalisations for each recommendation with measures to be considered as denominators and numerators are given as well to suggest quality indicators for future benchmarking across European countries. Further pan-European research will need to show whether the implementation of this guidance will lead to improved quality of mental healthcare, and may help to develop useful country-specific cutoffs for the suggested quality indicators.

Persistent depressive disorder across the adult lifespan: results from clinical and population-based surveys in Germany

BACKGROUND

Although the individual and economic disease burden of depression is particularly high for long-term symptoms, little is known of the lifetime course of chronic depression. Most evidence derives from clinical samples, and the diagnostic distinction between persistent depressive disorder (PDD) and non-chronic major depression (NCMDD) is still debated. Thus, we examined characteristics of PDD among clinical vs. non-clinical cases, and the associated disease burden at a population level.

METHODS

Data were drawn from the mental health module of the German Health Interview and Examination Survey for Adults (DEGS1-MH, 2009-2012, n = 4483) and a clinical sample of PDD inpatients at Charité - Universitätsmedizin Berlin (2018-2019, n = 45). The DSM-5 definition of PDD was operationalized a priori to the study using interview-based DSM-IV diagnoses of dysthymia and major depression lasting at least 2 years in both surveys. Additional depression characteristics (depression onset, self-classified course, suicidality, comorbid mental disorders, treatment history and current depressive symptoms [Patient Health Questionnaire-9]) were assessed. In the DEGS1-MH, health-related quality of life (Short Form Health Survey-36, SF-36), chronic somatic conditions, number of sick days (past 12 months) or days with limitations in normal daily life activities (past 4 weeks), and health service utilization (past 12 months) were compared for PDD vs. NCMDD.

RESULTS

PDD cases from the clinical sample had a significantly earlier depression onset, a higher proportion of self-classification as persistent course, and treatment resistance than PDD and NCMDD cases in DEGS1-MH. At a population level, PDD cases showed worse outcomes compared with NCMDD cases in terms of somatic comorbidity, SF-36 mental component score, and activity limitations owing to mental health problems, as well as a higher risk for outpatient mental health care contact.

CONCLUSIONS

The distinction between PDD and NCMDD proposed for DSM-5 seems warranted. Early onset depression, self-classification as persistent depressive course, and treatment resistance are suggested as markers of more severe and chronic depression courses. At a population level, PDD is associated with remarkably higher individual and economic disease burden than NCMDD, highlighting the need to improve medical recognition of chronic courses and establish specific treatment concepts for chronic depression.