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      Factors associated with health service utilisation for common mental disorders: a systematic review

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          There is a large treatment gap for common mental disorders (CMD), with wide variation by world region. This review identifies factors associated with formal health service utilisation for CMD in the general adult population, and compares evidence from high-income countries (HIC) with that from low-and-middle-income countries (LMIC).


          We searched MEDLINE, PsycINFO, EMBASE and Scopus in May 2016. Eligibility criteria were: published in English, in peer-reviewed journals; using population-based samples; employing standardised CMD measures; measuring use of formal health services for mental health reasons by people with CMD; testing the association between this outcome and any other factor(s). Risk of bias was assessed using the adapted Mixed Methods Appraisal Tool. We synthesised the results using “best fit framework synthesis”, with reference to the Andersen socio-behavioural model.


          Fifty two studies met inclusion criteria. 46 (88%) were from HIC.

          Predisposing factors: There was evidence linking increased likelihood of service use with female gender; Caucasian ethnicity; higher education levels; and being unmarried; although this was not consistent across all studies.

          Need factors: There was consistent evidence of an association between service utilisation and self-evaluated health status; duration of symptoms; disability; comorbidity; and panic symptoms. Associations with symptom severity were frequently but less consistently reported.

          Enabling factors: The evidence did not support an association with income or rural residence. Inconsistent evidence was found for associations between unemployment or having health insurance and use of services.

          There was a lack of research from LMIC and on contextual level factors.


          In HIC, failure to seek treatment for CMD is associated with less disabling symptoms and lack of perceived need for healthcare, consistent with suggestions that “treatment gap” statistics over-estimate unmet need for care as perceived by the target population. Economic factors and urban/rural residence appear to have little effect on treatment-seeking rates. Strategies to address potential healthcare inequities for men, ethnic minorities, the young and the elderly in HIC require further evaluation. The generalisability of these findings beyond HIC is limited. Future research should examine factors associated with health service utilisation for CMD in LMIC, and the effect of health systems and neighbourhood factors.

          Trial registration

          PROSPERO registration number: 42016046551.

          Electronic supplementary material

          The online version of this article (10.1186/s12888-018-1837-1) contains supplementary material, which is available to authorized users.

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          Most cited references 91

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          Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys.

          Mental disorders are major causes of disability worldwide, including in the low-income and middle-income countries least able to bear such burdens. We describe mental health care in 17 countries participating in the WHO world mental health (WMH) survey initiative and examine unmet needs for treatment. Face-to-face household surveys were undertaken with 84,850 community adult respondents in low-income or middle-income (Colombia, Lebanon, Mexico, Nigeria, China, South Africa, Ukraine) and high-income countries (Belgium, France, Germany, Israel, Italy, Japan, Netherlands, New Zealand, Spain, USA). Prevalence and severity of mental disorders over 12 months, and mental health service use, were assessed with the WMH composite international diagnostic interview. Logistic regression analysis was used to study sociodemographic predictors of receiving any 12-month services. The number of respondents using any 12-month mental health services (57 [2%; Nigeria] to 1477 [18%; USA]) was generally lower in developing than in developed countries, and the proportion receiving services tended to correspond to countries' percentages of gross domestic product spent on health care. Although seriousness of disorder was related to service use, only five (11%; China) to 46 (61%; Belgium) of patients with severe disorders received any care in the previous year. General medical sectors were the largest sources of mental health services. For respondents initiating treatments, 152 (70%; Germany) to 129 (95%; Italy) received any follow-up care, and one (10%; Nigeria) to 113 (42%; France) received treatments meeting minimum standards for adequacy. Patients who were male, married, less-educated, and at the extremes of age or income were treated less. Unmet needs for mental health treatment are pervasive and especially concerning in less-developed countries. Alleviation of these unmet needs will require expansion and optimum allocation of treatment resources.
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            Changes in racial-ethnic disparities in use and adequacy of mental health care in the United States, 1990–2003.

            This study examined changes in white-black and white-Latino disparities in the use of any mental health care and minimally adequate mental health care. Using data from the 1990–1992 National Comorbidity Survey (NCS) and the 2001–2003 National Comorbidity Survey Replication (NCS-R), this study examined changes by race-ethnicity in use of mental health care among individuals age 18 to 54 with a 12-month mood or anxiety disorder. The sample consisted of 1,198 NCS respondents and 929 NCS-R respondents. Changes in disparities were estimated in the use of any mental health care in the general medical sector, the specialty mental health sector, and in total. Changes in disparities were also estimated in the use of minimally adequate mental health care (in total only). Disparities in the use of any mental health care increased over time, particularly between non-Latino whites and non-Latino blacks in the general medical sector and between non-Latino whites and Latinos in the specialty mental health sector. Disparities in the use of minimally adequate mental health care persisted between whites and blacks over time but were not detected between whites and Latinos in either period. The findings of greater racial-ethnic disparities in the general medical and specialty mental health sectors indicate that more targeted policies and programs are needed to increase use of mental health care in these health sectors among persons from racial-ethnic minority groups. The persistence of white-black disparities in the use of minimally adequate mental health care warrants further examination.
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              Dropping out of treatment: a critical review.


                Author and article information

                020 7299 4681 , tessa.roberts@lshtm.ac.uk , tessa.roberts@kcl.ac.uk
                BMC Psychiatry
                BMC Psychiatry
                BMC Psychiatry
                BioMed Central (London )
                22 August 2018
                22 August 2018
                : 18
                [1 ]ISNI 0000 0004 0425 469X, GRID grid.8991.9, Centre for Global Mental Health, Department of Population Health, Faculty of Epidemiology and Population Health, , London School of Hygiene and Tropical Medicine, ; Keppel Street, London, WC1E 7HT UK
                [2 ]ISNI 0000 0001 2322 6764, GRID grid.13097.3c, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, , King’s College London, ; London, UK
                [3 ]GRID grid.447902.c, Department of Social Psychiatry, , National Institute of Mental Health, ; Prague, Czech Republic
                [4 ]ISNI 0000 0001 2322 4988, GRID grid.8591.5, Institute of Global Health, , University of Geneva, ; Geneva, Switzerland
                [5 ]ISNI 0000 0004 1761 0198, GRID grid.415361.4, Centre for Chronic Conditions and Injuries, , Public Health Foundation of India, ; New Delhi, India
                [6 ]ISNI 0000 0001 0481 6099, GRID grid.5012.6, Care and Public Health Research Institute, , Maastricht University, ; Maastricht, Netherlands
                [7 ]ISNI 000000041936754X, GRID grid.38142.3c, Department of Global Health and Social Medicine, , Harvard Medical School, ; Boston, USA
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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                © The Author(s) 2018


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