Use of Primary and Specialized Mental Health ... - Psychiatric Services

Use of Primary and Specialized Mental Health Care for a Major Depressive Episode in Spain by ESEMeD Respondents Andrea Gabilondo, M.D. Sònia Rojas-Farreras, M.Sc. Angel Rodríguez, M.D. Ana Fernández, M.D., Ph.D. Alejandra Pinto-Meza, M.D., Ph.D. Gemma Vilagut, M.Sc. Josep M. Haro, M.D., Ph.D. Jordi Alonso, M.D., Ph.D.

Objective: This study described use of services for a major depressive episode and determined factors associated with use in Spain, a country with universal access to care and a relatively low prevalence of depression. Methods: Data were from the European Study of the Epidemiology of Mental Disorders (ESEMeD). ESEMeD-Spain was a cross-sectional, general population survey conducted with a representative sample of noninstitutionalized adults (N=5,473). The Composite International Diagnostic Interview was used, and 12-month use of services for a major depressive episode, types of services used, and receipt of minimally adequate treatment were assessed. Results: Among the 247 respondents with a major depressive episode in the past 12 months, 59% reported any use of past-year services for their disorder; of this group, 76% reported receipt of any active treatment (from a health care or mental health professional). Among respondents with severe depression, 31% used no services. A higher likelihood of service use was found among those who were unemployed or too disabled to work (OR=4.9, CI=1.3–19), who had moderate depression symptoms (OR=3.2, CI=1.1–9.0), and who had one mental disorder comorbid with depression (OR=2.9, CI=1.2–7.0) or two or more such comorbid disorders (OR=4.1, CI=1.9–8.9). In the active treatment group, only 31.2% received treatment that was minimally adequate. Conclusions: There is a need in Spain to increase use of services for a major depressive episode, especially among certain population groups, such as women, and to improve adequacy of treatments. The role of specific factors, such as availability of services and of professionals, deserves further research. (Psychiatric Services 62:152–161, 2011) Dr. Gabilondo, Ms. Rojas-Farreras, Ms. Vilagut, and Dr. Alonso are affiliated with the Health Services Research Unit, IMIM-Hospital del Mar, Barcelona, Spain. Dr. Gabilondo is also with the Department of Health, Directorate General for Public Health, Government of Catalonia, Barcelona. Ms Vilagut and Dr. Alonso are also with CIBER en Epidemiología y Salud Pública, Barcelona. Dr. Rodríguez is with the Teaching Unit, Parc de Salut MarUPF-ASPB, Barcelona. Dr. Fernández, Dr. Pinto-Meza, and Dr. Haro are with the Fundació Sant Joan de Déu, Sant Boi de Llobregat, Spain. Dr. Fernández and Dr. Pinto-Meza are also with Red de Investigación en Actividades Preventivas y Promoción de la Salud en Atención Primaria, Barcelona. Dr. Haro is also with CIBER en Salud Mental, Barcelona. Send correspondence to Dr. Alonso at IMIM-Hospital del Mar, C/ Doctor Aiguader, 88, 08003 Barcelona, Spain (e-mail: [email protected]). 152

PSYCHIATRIC SERVICES

D

epression is of high public health concern because it is the most common mental disorder and a primary cause of disease burden, disability (1), long-term sickness, absence from work, and premature retirement (2). Furthermore, it has been described as the most costly brain disorder in Europe (3). In southern European countries, prevalence rates of depression and suicide are lower than elsewhere in Europe (4,5), and a recent study of depression in Spain, one of the largest southern European countries, found additional characteristics specific to this country, such as an earlier age at onset and higher rates of comorbidity and of chronicity (5). Health services are a crucial resource in reducing the suffering of persons with depression; however, studies have found large differences between countries in rates of depression treatment, with low overall rates (6–8). Although health care systems vary widely across the world, certain system characteristics, such as access to services, number of health professionals, and quality of care, contribute to the outcomes of depression treatment. Studies of service use for the treatment of depression are scarce and mostly limited to Western and Northern European countries. Although information from many countries, such as Spain,

o ps.psychiatryonline.org o February 2011 Vol. 62 No. 2

is available, it remains fragmented and incomplete. The Spanish National Health System provides free and universal access to most types of health care. It is financed by general taxation and by out-of-pocket expenditures, including copayments for pharmacological treatments. The primary care sector acts as the gatekeeper to the system and therefore to specialized mental health care. Because administration of health care is decentralized and is the responsibility of the 17 Autonomous Communities, the number and quality of mental health services is not homogeneous across Spain. Frequently described deficiencies include lack of specific budgets for mental health, heterogeneous information systems, and insufficient coordination with primary care services (9). The objective of this study was to analyze service use in the past 12 months for a major depressive episode among respondents to the European Study of the Epidemiology of Mental Disorders (ESEMeD), in Spain. We estimated the level of use of services, determined the proportion of individuals using services who could be considered to have received minimally adequate treatment, and identified the sociodemographic and clinical factors associated with service use. We also compared these results with international data.

main respondents, who were also interviewed); the final response rate was 78.6%. Data collection was conducted from September 2001 to September 2002. Individuals provided informed consent to participate in the interview. Data for the individuals were weighted to account for the different probabilities of selection within households and among hard-toreach individuals, as well as to reflect age, gender, and Autonomous Community distribution of the Spanish general population.

Methods

Assessment of depression severity Respondents were assessed for major depressive episode in the past 12 months. On the basis on researchers’ consensus, individuals with the disorder were classified into three severity groups. The group with the most severe symptoms included those who had attempted suicide in the past 12 months, those who had a diagnosis of alcohol dependence with physiological dependence syndrome, and those who experienced severe role impairment (scores from 8 to 10) in at least two areas of the WMH-adapted version of the Sheehan Disability Scales (SDS). Individuals not classified as having severe symptoms were assigned to the moderate group if they had moderate role impairment in at least one domain of the SDS (a score

The ESEMeD-Spain study was a cross-sectional, general population, household survey conducted with a representative sample of the Spanish noninstitutionalized adult population. A detailed description of methods is available elsewhere (10–12). Sampling methods A stratified, multistage, clusteredarea, probability sample without replacement design was used to guarantee the representativeness of all the regions in the country. The target population was noninstitutionalized adults (aged 18 years and older), who were identified from census tract data. The final sample included 5,473 respondents (including a random selection of 323 spouses of the married PSYCHIATRIC SERVICES

Interview and questionnaire The survey instrument was the World Mental Health (WMH) Survey version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI 3.0) (13), which is a fully structured diagnostic interview to assess disorders and treatment, as well as several additional variables, such as disease severity and disability. By means of computerized algorithms, the CIDI provides lifetime and 12-month diagnoses of mental disorders based on DSM-IV criteria (14). In establishing the diagnosis, CIDI rules about excluding organic mental disorders (direct physiological effects of a general medical condition, a drug, or a medication) were imposed. The CIDI was administered by trained lay interviewers using a computer-assisted personal interview.


of more than 4) or if they had alcohol dependence disorder without physiological dependence. All other individuals were classified as having mild symptoms. Health and social services use All respondents were asked about use of services for their “emotions or mental health problems” in the 12 months before the interview. Those reporting use of services were asked to select from a list all providers whom they visited, including psychiatrist; psychologist; general practitioner, other physician, or other health care professional; human services (outpatient treatment with a religious or spiritual advisor or with a social worker or counselor in any setting other than a specialty mental health setting); and a complementary-alternative medical sector (outpatient treatment with any other type of healer, participation in an Internet support group, or participation in a selfhelp group). Psychiatrists and psychologists constituted the specialized mental health category; general practitioners, other physicians, and other health professionals constituted the general medical care category; and both specialized mental health and general medical care constituted the health care sector. The type of treatment received by individuals who reported use of a service in the health care sector was assessed. Pharmacological treatment was defined as that prescribed by a psychiatrist, general practitioner, or any other physician or health professional in the previous 12 months. Psychotherapy was defined as having more than one session in the past 12 months of psychological counseling or therapy with a mental health professional (psychiatrist or psychologist) that lasted 15 minutes or longer. Individuals who received neither drug nor psychological treatment were classified as being in the group with no active treatment. Treatment adequacy The definition of minimally adequate treatment followed previous research that was based on recommendations from clinical guidelines (15–17). It was defined as receipt of antidepres153

sant pharmacotherapy for at least two months plus at least four visits with a psychiatrist, a general practitioner, or any other physician or health professional or at least eight sessions with a psychologist or a psychiatrist lasting an average of 15 minutes or longer. Human services and complementaryalternative medicine treatments were not considered to constitute adequate care because of the lack of experimental data documenting the effectiveness of such treatments for major depression (18–22). Chronic conditions and mental disorder variables The variable for chronic conditions included eight groups: musculoskeletal (arthritis), chronic pain (neck or back pain or other somatoform pain), digestive (stomach or intestinal ulcer), respiratory (asthma, allergies, or any other chronic lung disease), neurological problems, cancer, cardiovascular (stroke, heart attack, heart disease, or high blood pressure), and diabetes. The variable for mental disorders included mood disorders (major depressive episode or dysthymia), anxiety disorders (panic disorder, specific phobia or social phobia, generalized anxiety disorder, posttraumatic stress disorder, and agoraphobia without panic), and alcohol abuse or dependence. Data analysis All analyses were performed with SASTM software, version 9.1, of the SAS System for Windows as well as SUDAAN, version 9.0, a statistical package used to estimate standard errors of data obtained from surveys with complex designs. Data analyses were carried out at the IMIM-Hospital del Mar in Barcelona, Spain, and at Harvard University in Boston.

Results Lifetime prevalence of a major depressive episode in the overall sample was 10.6%, and 12-month prevalence was 4.0%. Table 1 presents data on sociodemographic characteristics of the total sample and of those with a lifetime and 12-month major depressive episode. Among respondents with a depressive disorder in the past 12 months, 154

59.1% had used some type of service in the past 12 months for their emotional problems. As shown in Table 2, the highest proportion of service users (58.7%) reported use of services in the health care sector (either general medical care or specialized mental health). Among those who used services in the health care sector, the highest proportion reported use only in general medical care (35.3%). Among respondents who had used past-year services for emotional problems in the heath care sector, at least 76% received some type of active treatment: 70.1% reported receiving psychopharmacological treatment, either alone (37.9%) or combined with psychotherapy (32.2%). Receipt of no active treatment was highest among respondents with moderate major depressive episode (10.9%) and lowest among those with a mild disorder (5.0%). As shown in Table 3, among respondents who had received active treatment in the past 12 months from providers in the health care sector, 31.2% received treatment that met criteria for minimal adequacy. In the overall sample, meaningful differences were found by type of health service used: respondents who received both specialized mental health care and general medical care accounted for the highest proportion of those receiving minimally adequate care (38.6%), and the lowest proportion was among those who received services in general medical care only (12.8%). These differences were also found among respondents with severe major depressive episode. Results of logistic regression analyses of potential predictors of pastyear service use among respondents with a 12-month major depressive episode are shown in Table 4. Respondents in the group aged 35–49 years were more likely than those in the other age groups to have used any services for their emotional problems within the past year (OR=5.7). Service use was also more likely among those in the “other” employment group (unemployed or too disabled to work) (OR=4.9), compared with those who were employed. Respondents who had a moderate disorder PSYCHIATRIC SERVICES

were more likely (OR=3.2) than those in the other severity groups to have used any services. Respondents who had more than one 12-month mental disorder (that is, a mental disorder comorbid with their depression) were significantly more likely than those with depression only to use any services (two mental disorders, OR=2.9; three or more mental disorders, OR=4.1). On the other hand, respondents with a low-average income were less likely than those with a high income to have used any services for their emotional problems in the past 12 months (OR=.3). The regression analyses also examined use of specialized mental health services in the past 12 months (Table 4). Respondents in the group aged 35–49 were more likely than those aged 18–34 to use these services (OR=3.0). Those with a severe or moderate disorder were significantly more likely to use these services than those with a mild disorder (OR=5.1 and OR=4.7, respectively). On the other hand, those with a high-average education level were less likely than those with a high level to use specialized services (OR=.3).

Discussion The study found that 40.9% of respondents to ESEMeD-Spain with a 12-month major depressive episode reported not having used any type of service for their emotional problems in the past year. Moreover, 68.8% of those who received active treatment in the health care sector (specialized mental health or general medical care) did not receive minimally adequate treatment. Thus only 15.0% of all those with a 12-month major depressive episode had received appropriate care. Of particular concern is the 30.8% of those with a severe disorder who did not use any type of service for their emotional problems. By far, psychotropic medication was the treatment most used, either alone or (less frequently) in combination with psychological treatment. Higher odds of any service use were found among respondents with a moderate disorder, those with a comorbid mental disorder, those who were unemployed or too disabled to work, and middle-aged respondents.


Table 1

Characteristics of respondents in the European Study of the Epidemiology of Mental Disorders in Spain, by lifetime and 12-month diagnosis of a major depressive episodea Lifetime major depressive episode

Total sample Characteristic

N

%

Total Age group 18–34 35–49 50–64 ≥65 Sex Male Female Education Low Low-average High-average High Marital status Married or cohabiting Separated, widowed, or divorced Never married Urbanicity (inhabitants) 100,000 Employment Working Student Homemaker Retired Otherb Income Low Low-average High-average High Severity of depression Severe Moderate Mild None Mental disorders in past 12 months None 1 2 ≥3 Chronic general medical conditions in past 12 months None 1 2 ≥3

5,473

100.0

1,567 1,431 1,024 1,451

34.3 25.7 19.4 20.6

2,421 3,052

a b

SE (%)

12-month major depressive episode

N

%

672

10.6

.5

247

4.0

.3

.8 .6 .5 .5

167 194 160 151

29.4 28.6 22.9 19.0

2.2 2.0 1.8 1.9

61 62 66 58

30.8 24.4 26.5 18.4

4.5 3.4 3.2 2.6

47.8 52.2

.7 .7

174 498

28.9 71.1

2.4 2.4

56 191

25.9 74.1

3.3 3.3

1,545 1,747 960 1,221

25.8 31.7 19.2 23.3

.8 .6 .7 1.1

215 214 106 137

29.0 32.7 17.3 21.0

2.3 2.1 1.3 2.3

87 69 42 49

30.2 25.8 20.4 23.6

3.5 3.5 2.8 3.7

3,674 722 1,077

65.3 9.0 25.7

.7 .4 .7

406 153 113

61.3 16.6 22.1

2.2 1.7 2.4

153 53 41

62.8 14.9 22.3

4.0 2.3 3.6

1,411 2,000 2,062

25.6 35.1 39.3

2.5 2.7 3.2

151 254 267

23.3 38.7 38.0

3.2 3.3 3.2

50 87 110

23.1 36.1 40.8

3.2 4.1 3.7

2,582 213 922 1,321 435

50.1 5.9 16.2 19.2 8.6

.9 .4 .7 .5 .5

301 13 123 123 112

44.6 3.3 19.9 16.6 15.6

2.4 .9 2.1 1.5 1.5

91 8 47 49 52

38.4 6.1 19.9 17.3 18.3

3.2 2.2 3.0 2.9 2.4

769 1,734 1,952 1,018

17.3 32.8 34.2 15.8

.8 .8 .8 .6

111 214 236 111

21.0 34.7 30.4 13.9

2.9 2.3 2.1 1.7

37 84 86 40

17.3 35.0 32.2 15.4

3.3 3.3 2.9 2.9

132 215 202 4,924

2.1 3.7 3.9 90.3

.2 .3 .3 .5

110 123 74 365

15.7 18.8 12.7 52.8

1.9 1.5 1.5 1.9

100 99 48 0

37.3 38.2 24.5 —

4.0 3.9 2.8

4,937 375 105 56

90.6 6.8 1.8 .9

.5 .4 .2 .1

369 155 92 56

53.2 24.6 14.0 8.2

1.9 2.3 1.6 1.2

0 106 86 55

— 43.2 35.4 21.5

— 5.5 4.0 3.2

4,459 517 281 216

82.7 9.1 4.8 3.4

.6 .4 .3 .3

303 167 106 96

47.3 23.3 15.2 14.2

2.3 1.8 1.4 1.5

95 66 44 42

43.0 21.7 15.9 19.4

3.2 2.5 2.2 2.3

—

SE (%)

N

%

SE (%)

Ns are unweighted, and percentages are weighted. Unemployed or too disabled to work

Study limitations and strengths Our results should be interpreted within the context of some limitations. First, information about treatment was self-reported, which could have led to recall bias. Previous studPSYCHIATRIC SERVICES

ies have found that self-reports of service use for some mental disorders may be higher than use documented in administrative records (23,24). The WMH Survey tried to reduce recall bias by excluding respondents who


failed to say that they would think carefully and answer honestly. Furthermore, use of a 12-month time frame can further reduce the risk of recall bias. Second, some analyses consisted of small numbers of respon155

Table 2

Use of services for emotional problems in the past 12 months by respondents in the European Study of the Epidemiology of Mental Disorders in Spain with a 12-month major depressive episode, by severity of the disordera Total with a 12-month major depressive episode (N=247) Type of service and treatment Any health-sector services Service used in health sector Only mental health care Only general medical caref Both mental health and general medical caref Only human services or complementary-alternative medicine No use of any services Treatment received by health-sector service users Only drug treatment Only psychotherapy Both drug treatment and and psychotherapy No information No active treatmenti a b c d e f g h i

Severe disorder Moderate dis(N=100) order (N=99)

Mild disorder (N=48)

SE (%) N

SE (%) χ2

df p

51 33.5 52 35.3

3.6 51.9b 5.8d 4.2 4.8

2 10,000 inhabitants 10,000–100,000 >100,000 Employment Working Student Homemaker Retired Otherb Income Low Low-average High-average High Severity of depression Severe Moderate Mild 12-month mental disorders 1 2 ≥3 12-month chronic general medical conditions None 1 2 ≥3 a b

%

SE (%) OR

Wald 95% CI test df 2.2

33 48 40 34

48.5 72.4 60.1 57.9

8.1 9.6 8.5 7.4

1 3

SE (%)

N

%

OR

95% CI

22 35 28 15

31.7 53.2 39.1 26.5

5.7 1.00 1.0–1.0 5.8 3.04 1.1–8.4 6.4 1.65 .7–4.0 6.5 .91 .2–4.1

23 77

41.6 36.7

6.2 1,00 1.0–1.0 3.8 .76 .3–2.2

31 33 12 24

35.1 50.1 21.7 42.3

5.5 .70 .2–2.0 7.1 1.02 .3–3.1 6.5 .30 .1–.8 7.7 1.00 1.0–1.0

.1

.37

10.2 1.00 1.0–1.0 3.8 1.79 .5–6.5 .55

53 46 23 33

p

1.00 1.0–1.0 5.69 1.4–24 2.02 .6–6.4 1.96 .3–13 .82

30 54.2 125 60.8

3

Use of specialized mental health services (N=100)

.652

61.4 65.7 45.4 60.9

6.3 .78 .3–2.4 7.3 .99 .2–5.1 10.9 .55 .2–1.8 9.3 1.00 1.0–1.0

92 55.4

5.2 1.00 1.0–1.0

58

35.3

4.4 1.00 1.0–1.0

38 77.5 25 57.3

6.8 2.17 9.7 1.70

24 18

47.0 39.4

9.2 1.54 8.7 1.28

31 59.9 54 61.1 70 56.9

8.2 1.00 1.0–1.0 7.5 .69 .2–1.9 6.3 .58 .3–1.3

16 38 46

27.2 44.8 38.0

5.9 1.00 1.0–1.0 4.5 2.12 .7–6.1 5.8 1.55 .6–3.9

36 2 14 17 31

35.6 6.1 1.00 1.0–1.0 13.1 10.2 .29 .0–3.1 31.2 9.2 .83 .2–3.7 34.6 7.3 1.09 .2–5.5 61.8 7.1 2.67 .7–9.6

20 30 33 17

54.0 11.7 1.27 .3–4.9 34.3 6.5 .79 .3–2.4 32.1 4.8 .72 .3–1.9 40.3 13.2 1.00 1.0–1.0

47 42 11

47.0 43.9 14.9

5.5 5.13 1.9–14.0 4.7 4.67 1.9–11.0 4.7 1.00 1.0–1.0

47 28 25

40.0 36.0 37.0

6.0 1.00 1.0–1.0 6.2 .77 .3–1.7 8.0 .83 .4–1.7

40 28 20 12

40.7 42.6 37.9 26.6

4.8 1.00 1.0–1.0 5.6 .86 .4–1.7 9.2 1.12 .5–2.8 7.7 .67 .2–2.0

.86

2.42 55 4 24 32 40

52.3 40.1 53.1 63 82.7

6.6 1.00 1.0–1.0 18.4 .56 .1–3.7 9.3 .77 .2–2.8 6.7 1.81 .3–10 5.8 4.93 1.3–19

29 45 53 28

80.7 50.1 55.4 63.1

8.3 .86 .2–3.7 7.7 .28 .1–.8 6.9 .52 .2–1.4 9.6 1.00 1.0–1.0

70 69.2 63 62.3 22 38.9

5.4 3.05 1.0–9.0 5.2 3.16 1.1–9.0 10.6 1.00 1.0–1.0

61 48.3 54 64.6 40 71.8

6.4 1.00 1.0–1.0 5.2 2.87 1.2–7.0 7.2 4.08 1.9–8.9

1.98

2.59

7.77

1.00 59.0 64.6 53.6 57.7

.429

.6–7.7 .4–6.9 .88

60 43 29 23

2

2

4

3

2

2

3

1.95

3

.135

.26

1

.613

2.24

3

.196

.29

2

.749

1.04

2

.36

1.96

4

.116

.52

3

.67

6.27

2

.004

.26

2

.769

.30

3

.826

.5–5.0 .4–4.2

.421

.061

.13

.086

.001

.400

6.5 1.00 1.0–1.0 6.6 .81 .3–2.0 10.3 .35 .1–1.2 8.8 .50 .1–1.8

Wald test df p

Ns are unweighted, and percentages are weighted. Unemployed or too disabled to work

management relies on each regional government. As a consequence, the level of development of the mental health network, the allocation of economic resources, and the population density of professionals vary across regions; these differences may influence the use of services. Because of PSYCHIATRIC SERVICES

limitations in sample size, it was not possible to perform a more detailed analysis that would offer a clearer picture of probable regional differences. With these limitations in mind, we note that this is the first study that provides information about the use of services for a major depressive


episode in Spain that is based on a nationally representative sample and that used a standardized methodology that allows for international comparisons. Previous research was restricted to specific regions and population subgroups (25, 26) or clinical samples (27) or used 157

mixed methodologies, which provided an incomplete picture of service use for depression. Use of services Our findings show that almost half of respondents with a major depressive episode did not use services in the health care sector for their emotional problems in the year before the interview. Although concrete and easily comparable data are lacking, some studies have found lower use of health services for mental disorders in certain southern European countries, such as Spain and Italy, compared with other European countries, but the rates are still higher than those found in many low-income American samples or in Asian countries (6,28). Comparable data on service use by individuals with major depression are even scarcer, but studies have shown that use is higher in Spain than in countries such as Italy and Germany (29) and lower than in some northern European countries, such as Finland, Ireland, and the United Kingdom (30). Although underrecognition and undertreatment of common mental disorders are frequent in most countries, substantive cross-national differences in treatment rates have been described. Treatment rates ranging from 50% to 79% in high-income countries have been reported, with rates typically lower in low-income regions (6). Reasons for these differences are not well known, but several factors have been proposed. They include factors that predispose patients to seek treatment, factors related to the type and amount of services available from the health care system, and factors related to health care professionals’ ability to provide an adequate response to the need for treatment (6,31–35). The effect of social networks and support, which might be stronger in Spain than in other European countries (36), has also been discussed in the literature as either reducing service use by helping an individual to cope with stress or increasing service use by supporting treatment seeking (37). Although an extensive review of these factors is beyond the scope of this article, the relevant findings are summarized below. 158

Patient-related factors. A personal level of comfort and confidence about consulting with professionals has been considered the most important factor in help seeking for depression, together with personal understanding and self-evaluation of the problem and the anticipated or experienced reactions of family and friends (31,32). Attitudes toward seeking mental health care seem to be more positive in Spain than in other European countries, and Spaniards seem to place greater trust in treatments provided by health care professionals (38). In regard to stigma, a well-known cultural barrier to help seeking for mental disorders (32), two recent studies showed that stigma may be less prevalent in Spain than in other European countries (39,40). Health system–related factors. The ability to access professional care is a key feature of health systems and also influences service use for mental disorders. Access to services is free and universal in the Spanish National Health System, as is the case in many other European countries, where treatment rates are, however, higher. A link between a country’s overall spending on health care and the rate of treatment for mental disorders has also been described (6), and available data show that the amount spent in Spain is lower than the European average; this is also true of spending on mental health, which remains around 5% of Spain’s total health care budget— one of the lowest spending rates in the European Union (41–43). The availability of services and of professionals is another relevant determinant that has also been linked to the use of services for depression. Studies have shown that regions with the lowest resources often have lower rates of consultation with health care professionals (44). Spain has fewer psychiatrists and psychologists and fewer available mental health services than many other countries with the same level of development, and differences are even greater for psychiatric nurses and social workers (9,42,43). Factors related to health care professionals. The Spanish National Health System is based on primary PSYCHIATRIC SERVICES

care, and referral from a general practitioner is usually required to gain access to specialized mental health services. Thus general practitioners act as gatekeepers of the system and have a key role in the correct detection and early management of most cases of depression. This is especially relevant in light of the high prevalence of major depression in primary care (45) and the evidence linking poor recognition of depression in primary care with worse shortterm outcomes (46). In fact, underrecognition of depression in primary care has been extensively reported (47–49), and a recent meta-analysis that included more than 50,000 international patients showed that correct identification of depression by general practitioners occurred in only 47.3% of cases (50). This worrying situation has also been described in Spain (51,52), but international comparisons are scarce. Roles of general practitioners and mental health specialists Our results show that the proportion of respondents who sought service in the general medical care sector was only slightly higher than the proportion who visited mental health specialists. This finding is in contrast to other European countries and regions of the world, where general practitioners are clearly the professionals most frequently involved in the treatment of depression (6,44). This difference might be partly explained by the higher rates of referral to mental health specialists by general practitioners that have been described in Spain (44). These higher referral rates could be considered an attempt to improve the efficiency of a short-resourced health system. Additional factors, such as the relative delay in mental health care reform in Spain, may help explain why individuals with mild disorders were more likely to receive specialized mental health care. Sociodemographic and clinical correlates of use The likelihood of use of services for depression has been linked to a variety of sociodemographic factors, such as middle age, female gender, higher


education and income level, and not being married (6,16,53,54). However, our results support only a few of them. Of special concern is our finding that women were no more likely than men to seek treatment. This finding should receive attention because the higher prevalence of depression among women compared with men in Spain was found to be much higher than in many other countries (5,55,56). Symptom severity is another major determinant of service use (30,57, 58), and monotonic relationships between severity and the probability of service use have been previously described (6). Our results show that among individuals using any health sector services, those with a moderate disorder had higher odds of receiving treatment than individuals with mild disorders. Further research should be undertaken to confirm these findings—in particular, the role of severity and of gender in help seeking. Also, the finding that 31.7% of those with a severe disorder received care only from a general practitioner raises some concern about possible misallocations of scarce specialized resources, especially when the misallocations affect patients with higher risks of serious complications. Minimally adequate treatment In our study 31.2% of the patients with a major depressive episode who received active treatment from general medical or mental health specialty care received minimally adequate treatment, a rate considerably lower than in other European countries (17). Consistent with previous studies, our study found low overall rates of treatment adequacy (6,59) and more adequate treatment in specialized settings (16,60). Reasons for the low rate of treatment adequacy are unclear, but they presumably involve provider factors, such as inadequate training and failure to adhere to guidelines (16). Inadequate treatment has significant health and economic consequences, because treatments that meet clinical guidelines are more cost-effective and have been shown to decrease the number of years lived with a disability (61). PSYCHIATRIC SERVICES

Conclusions Taken together the results offer a complex picture of patterns of service use for a major depressive episode in Spain. They include a less clear influence of disorder severity, a less relevant role for general practitioners than for mental health specialists, varying effects of sociodemographic factors, and a lower overall rate of minimally adequate treatment. Low rates of service use for major depression in a country such as Spain, with free and universal access to mental health care and a population with more positive attitudes toward help seeking for mental health problems, are worrisome and should call for a more proactive attitude of the health system. In particular, rates of comorbidity and of chronicity are higher in Spain than in other European countries (5), and both are a possible consequence of inadequate treatment and a possible cause of increased costs of major depression. Potential country-specific barriers to treatment, such as lower availability of services and of professionals and lower health care spending for mental health, may contribute to the low rates of service use. Although there are many budgetary constraints and competing priorities, reducing these barriers to treatment should be seriously considered to improve access to mental health care in Spain. Efforts should be made to enable general practitioners to better detect and manage depression, which may involve changes in their training and more effective development and dissemination of clinical guidelines. In addition, the fact that no gender differences were found in the likelihood of receiving treatment should stimulate specific actions aimed at increasing treatment rates among women as a high-risk population group. This is also true for the youngest cohorts, especially considering that the age at onset of depression is lower in Spain (early 30s) than the European average (late 30s) (5) and that early intervention can improve the prognosis of this often chronic and highly disabling disorder. Acknowledgments and disclosures The ESEMeD project (www.epremed.org) was funded by contracts QLG5-1999-01042 and


SANCO-2004123 from the European Commission; the Piedmont Region of Italy; grant FIS 00/0028-02 from the Fondo de Investigación Sanitaria (FIS), Instituto de Salud Carlos III, Spain; grant SAF 2000-158-CE from the Ministerio de Ciencia y Tecnología, Spain; Departament de Salut, Generalitat de Catalunya, Spain; and by other local agencies and by an unrestricted educational grant from GlaxoSmithKline. ESEMeD is carried out in conjunction with the WHO WMH Survey Initiative. The authors thank the WMH staff for assistance with instrumentation, fieldwork, and data analysis. These activities were supported by grant R01MH070884 from the U.S. National Institute of Mental Health; the John D. and Catherine T. MacArthur Foundation; the Pfizer Foundation; grants R13-MH066849, R01MH069864, and R01 DA016558 from the U.S. Public Health Service; grant FIRCA R03TW006481 from the Fogarty International Center; the Pan American Health Organization; the Eli Lilly and Company Foundation; Ortho-McNeil Pharmaceuticals, Inc.; GlaxoSmithKline; Bristol-Myers Squibb; and Shire. The funding institutions had no further role in study design; in collection, analysis, and interpretation of data; in report writing; or in the decision to submit the report for publication. The authors report no competing interests.

References 1. The Global Burden of Disease: 2004 Update. Geneva, World Health Organization, 2008 2.

Curran C, Knapp M, McDaid D, et al: Mental health and employment: an overview of patterns and policies across the 17 MHEEN countries. Journal of Mental Health 16:195–210, 2007

3.

Sobocki P, Jonsson B, Angst J, et al: Cost of depression in Europe. Journal of Mental Health Policy and Economics 9:87–98, 2006

4.

Health and Consumer Protection Directorate-General: The State of Mental Health in the European Union. Brussels, European Communities, 2004

5.

Gabilondo A, Rojas-Farreras S, Vilagut G, et al: Epidemiology of major depressive episode in a southern European country: results from the ESEMeD-Spain project. Journal of Affective Disorders 12:76–85, 2010

6.

Wang PS, Aguilar-Gaxiola S, Alonso J, et al: Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO World Mental Health Surveys. Lancet 370:841–850, 2007

7.

Mechanic D: Barriers to help-seeking, detection, and adequate treatment for anxiety and mood disorders: implications for health care policy. Journal of Clinical Psychiatry 68:20–26, 2007

8.

Davidson JR, Meltzer-Brody SE: The underrecognition and undertreatment of depression: what is the breadth and depth of the problem? Journal of Clinical Psychiatry 60:4–9, 1999

159

9. Mental Health Observatory of the Spanish Association of Neuropsychiatry: Analysis of Service Provision for Mental Health in the Spanish Autonomous Communities in December 2005. Reference Guide 7 [in Spanish]. Madrid, Asociación Española de Neuropsiquiatría, 2007 10. Alonso J, Angermeyer MC, Bernert S, et al: Sampling and methods of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica. Supplementum 420: 8–20, 2004

22. Management of Depression in Primary and Secondary Care. London, National Institute for Clinical Excellence, 2004 23. Rhodes AE, Fung K: Self-reported use of mental health services versus administrative records: care to recall? International Journal of Methods in Psychiatric Research 13:165–175, 2004 24. Rhodes AE, Lin E, Mustard CA: Self-reported use of mental health services versus administrative records: should we care? International Journal of Methods in Psychiatric Research 11:125–133, 2002

11. Alonso J, Ferrer M, Romera B, et al: The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) project: rationale and methods. International Journal of Methods in Psychiatric Research 11:55–67, 2002

25. Roca-Bennasar M, Gili-Planas M, FerrerPerez V, et al: Mental disorders and medical conditions: a community study in a small island in Spain. Journal of Psychosomatic Research 50:39–44, 2001

12. Haro JM, Palacin C, Vilagut G, et al: Epidemiology of mental disorders in Spain: methods and participation in the ESEMeDSpain project [in Spanish]. Actas Españolas de Psiquiatria 31:182–191, 2003

26. Haro JM, Salvador-Carulla L, Cabases J, et al: Utilisation of mental health services and costs of patients with schizophrenia in three areas of Spain. British Journal of Psychiatry 173:334–340, 1998

13. Kessler RC, Ustun TB: The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatric Research 13:93– 121, 2004

27. Sicras-Mainar A, Blanca-Tamayo M, Gutiérrez-Nicuesa L, et al: Impact of morbidity, resource use and costs on maintenance of remission of major depression in Spain: a longitudinal study in a population setting [in Spanish]. Gaceta Sanitaria 24:13–19, 2010

14. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000

28. European Opinion Research Group: The Mental Health Status of the European Population. Eurobarometer 58.2. Brussels, Directorate General for Health and Consumer Affairs, 2003

15. Alonso J, Bruffaerts R, Gabilondo A, et al: Depression; in Major and Chronic Diseases: Report 2007. Report of the Task Force on Major and Chronic Diseases of DG SANCO’s Health Information Strand. Luxembourg, European Commission, 2008 16. Wang PS, Lane M, Olfson M, et al: Twelvemonth use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62:629–640, 2005 17. Fernández A, Haro JM, Martinez-Alonso M, et al: Treatment adequacy for anxiety and depressive disorders in six European countries. British Journal of Psychiatry 190:172–173, 2007 18. Practice guideline for treatment of patients with major depressive disorder. American Journal of Psychiatry 157(Apr suppl):1–45, 2000 19. Outpatient Management of Depression. Toronto, Centre for Effective Practice, Guidelines Advisory Committee, 2001 20. Kessler RC, Berglund P, Demler O, et al: The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 289:3095–3105, 2003 21. Royal Australian and New Zealand College of Psychiatrists: Australian and New Zealand clinical guidelines for the treatment of panic disorder and agoraphobia. Australian and New Zealand Journal of Psychiatry 37:641–656, 2003

160

156:115–123, 1999 36. Fernandez-Cordon, JA, Sgritta GB: The Southern Countries of the European Union: A Paradox? Presented at the annual seminar of European Observatory on the Social Situation, Demography and Family. Seville, Spain, September 15–6, 2000 37. Maulik PK, Eaton WW, Bradshaw CP: The effect of social networks and social support on mental health services use, following a life event, among the Baltimore Epidemiologic Catchment Area cohort. Journal of Behavioral Health Services and Research, Epub ahead of print, Feb 2010 38. Ten Have M, de Graaf R, Ormel J, et al: Are attitudes towards mental health helpseeking associated with service use? Results from the European Study of Epidemiology of Mental Disorders. Social Psychiatry and Psychiatric Epidemiology 45:153–163, 2010 39. Alonso J, Buron A, Rojas-Farreras S, et al: Perceived stigma among individuals with common mental disorders. Journal of Affective Disorders 118:180–186, 2009 40. Alonso J, Buron A, Bruffaerts R, et al: Association of perceived stigma and mood and anxiety disorders: results from the World Mental Health Surveys. Acta Psychiatrica Scandinavica 118:305–314, 2008 41. Salvador-Carulla L, Costa-Font J, Cabases J, et al: Evaluating mental health care and policy in Spain. Journal of Mental Health Policy and Economics 13:73–86, 2010

29. Kessler RC, Ustun TB (eds): The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders. New York, Cambridge University Press, 2008

42. Salvador-Carulla L, Montero I: Information for Evidence-Based Mental Health Planning [in Spanish]. Monografías de Psiquiatría vol 20, number 1. Madrid, Aula Médica Ediciones, 2008

30. McCracken C, Dalgard OS, Ayuso-Mateos JL: Health service use by adults with depression: community survey in five European countries: evidence from the ODIN study. British Journal of Psychiatry 189: 161–167, 2006

43. Salvador-Carulla L, Garrido M, McDaid D, et al: Financing mental health care in Spain: context and critical issues. European Journal of Psychiatry 20:29–44, 2006

31. Lin E, Parikh SG: Sociodemographic, clinical, and attitudinal characteristics of the untreated depressed in Ontario. Journal of Affective Disorders 53:153–162, 1999 32. Prins MA, Verhaak PF, Bensing JM, et al: Health beliefs and perceived need for mental health care of anxiety and depression: the patients’ perspective explored. Clinical Psychology Review 28:1038–1058, 2008 33. Paykel ES, Hart D, Priest RG: Changes in public attitudes to depression during the Defeat Depression Campaign. British Journal of Psychiatry 173:519–522, 1998 34. Burns BJ, Wagner HR, Gaynes BN, et al: General medical and specialty mental health service use for major depression. International Journal of Psychiatry in Medicine 30:127–143, 2000 35. Kessler RC, Zhao S, Katz SJ, et al: Pastyear use of outpatient services for psychiatric problems in the National Comorbidity Survey. American Journal of Psychiatry


44. Kovess-Masfety V, Alonso J, Brugha TS, et al: Differences in lifetime use of services for mental health problems in six European countries. Psychiatric Services 58:213–220, 2007 45. Serrano-Blanco A, Palao DJ, Luciano JV, et al: Prevalence of mental disorders in primary care: results from the diagnosis and treatment of mental disorders in primary care study (DASMAP). Social Psychiatry and Psychiatric Epidemiology 45:201–210, 2010 46. Simon GE, Goldberg D, Tiemens BG, et al: Outcomes of recognized and unrecognized depression in an international primary care study. General Hospital Psychiatry 21:97–105, 1999 47. Ustun TB, Von Korff M: Primary mental health services; in Mental Illness in General Health Care: An International Study. Edited by Ustun TB, Sartorius N. Chichester, United Kingdom, Wiley, 1995 48. Cepoiu M, McCusker J, Cole MG, et al: Recognition of depression by non-psychiatric physicians: a systematic literature re-


view and meta-analysis. Journal of General Internal Medicine 23:25–36, 2008 49. Hirschfeld R, Keller MB, Panico S, et al: The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA 277:333–340, 1997 50. Mitchell AJ, Vaze A, Rao S: Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 374:609–619, 2009 51. Aragonés E, Pinol JL, Labad A, et al: Detection and management of depressive disorders in primary care in Spain. International Journal of Psychiatry in Medicine 34:329–341, 2004 52. Aragonès E, Piñol JL, Labad A: The overdiagnosis of depression in non-depressed patients in primary care. Family Practice 23:363–368, 2006

53. Rhodes A, Goering P: Gender differences in the use of outpatient mental health services. Journal of Mental Health Administration 21:338–346, 1994 54. Olfson M, Klerman G.L: Depressive symptoms and mental health service utilization in a community sample. Social Psychiatry and Psychiatric Epidemiology 27: 161–167, 1992 55. Fryers T, Brugha T, Morgan Z, et al: Prevalence of psychiatric disorder in Europe: the potential and reality of meta-analysis. Social Psychiatry and Psychiatric Epidemiology 39:899–905, 2004 56. Paykel ES: Depression in women. British Journal of Psychiatry 158:22–29, 1991 57. WHO World Mental Health Survey Consortium: Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World

Mental Health Surveys. JAMA 291:2581– 2590, 2004 58. Bijl RV, de Graaf R, Hiripi E, et al: The prevalence of treated and untreated mental disorders in five countries. Health Affairs 22(3):122–133, 2003 59. Kessler RC, Merikangas KR, Wang PS: Prevalence, comorbidity, and service utilization for mood disorders in the United States at the beginning of the twenty-first century. Annual Review of Clinical Psychology 3:137–158, 2007 60. Knieser TJ, Powers RH, Croghan TW: Provider type and depression treatment adequacy. Health Policy 72:321–332, 2005 61. Andrews G, Issakidis C, Sanderson K, et al: Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. British Journal of Psychiatry 184:526–533, 2004

Coming in March o Understanding how mixed-methods designs are used in mental health services research: a review o Rates of mental disorders among youths three years after a traumatic physical injury: a population-based study o Prevention of mental and substance use disorders: steps toward the future of psychiatry o A communication model for discussing a new schizophrenia diagnosis with patients and families



161