Background
It is paramount for an individual with a mental difficulty to obtain an appropriate intervention. Although the proportion of treatment recipients is increasing, the majority of patients with psychiatric disorders worldwide still do not receive any professional health care [
1,
2]. Wang et al. [
2] reported the percentage of 12-month mental health service use across 17 countries; it ranged from 11.0% in China to 59.7% in United States for severe mental disorders, and 1.7% to 26.2%, respectively, for mild mental disorders. The unmet needs for mental health service would appear to be more serious in developing countries [
2‐
4].
With the goal of improving access to mental health care, epidemiological studies have identified factors associated with mental health service utilization (MHSU) (see [
5]. Most studies focused on socio-demographical predisposing factors, encompassing ethnic minorities [
6,
7], male gender [
8], and those with low education level [
9]. Cultural barriers, such as stigma [
10], misconception of mental health problems [
11], and mental health illiteracy [
12] may also shape negative attitudes toward professional service.
In line with efforts to investigate barriers to those seeking help for mental illness, Goodwin et al. [
9] underscored the effect of personality traits on MHSU. Personality factors are not just associated with mental illness itself [
13], but may also affect treatment seeking behavior. McWilliams et al. [
14] stressed considering personality-related factors to expand the scope of factors that affect MHSU, documenting the positive association of outpatient MHSU with self-criticism and locus of control. Most studies on personality traits and MHSU have examined the associations with particular personality traits. Using a nationally representative sample of Americans, Goodwin et al. [
9] revealed that five factor model was closely related to mental health service use among individuals with and without a diagnosed psychiatric disorder. Neuroticism was associated with increased MHSU, while conscientiousness was related to decreased MHSU among patients with any mental disorder. Ten Have et al. [
15] also confirmed that neuroticism was related to increased access to the mental health sector, regardless of whether individuals had an emotional disorder. In addition, Schomerus et al. [
16] suggested that high conscientiousness was related to higher access to mental health care among depressive patients, and Scholte-Stalenhoef et al. [
17] reported a positive association between openness and ambulatory care use among those with early psychotic symptoms. Considered together, the data indicate that MHSU is clearly associated with higher levels of neuroticism. But, the associations with the other four factors are mixed or unclear.
A negative attitude towards mental illness is pervasive in Asian culture [
10,
18‐
20]. Asians also seem to minimize mental health problems, considering them as problem to endure and overcome by their own will [
21,
22]. Asians who tend to suppress their emotions are less likely to recognize or admit their mental health needs [
11]. This cultural attitude fuels reluctance regarding MHSU [
11,
18,
23]. Considering the identified cultural barrier for people from Asians cultures, the role of personality traits in MHSU might differ among Asians. The present study used a nationally representative sample of Koreans to investigate the relationship between personality traits and MHSU among Korean adults with diagnosed mental disorders.
Results
Of the 1544 participants with lifetime psychiatric disorders, 17.8% (
n = 225; 95% CI = 15.9%–19.7%) had used mental health services. To identify possible confounders that may mediate the association between MHSU and personality constructs, we compared the socio-demographic characteristics and lifetime prevalence of psychiatric disorders between mental health service users and non-users. Mental health service users were older and more likely to be female and have low economic status compared to non-users. Depressive disorder (OR = 7.24, 95% CI = 5.45–9.62), dysthymia (OR = 3.41, 95% CI = 1.95–5.97), and anxiety disorder (OR = 2.15, 95% CI = 1.65–2.81) were positively associated with MHSU, and nicotine use disorder (OR = 0.54, 95% CI = 0.38–0.77) and alcohol use disorder (OR = 0.33, 95% CI = 0.24–0.45) were negatively associated with MHSU (Table
1).
Table 1
Socio-demographic and clinical correlates of mental health service utilization among KECA participants with lifetime mental disorder (n = 1544)
Female gender, n (%) | 203 (73.8) | 624 (49.2) | 2.92 (2.18–3.90) | <0.001 |
Age, |
18–34 | 51 (18.5) | 341 (26.9) | ref | |
35–54 | 114 (41.5) | 553 (43.6) | 1.38 (0.97–1.97) | 0.078 |
≥ 55 | 110 (40.0) | 375 (29.6) | 1.96 (1.36–2.82) | <0.001 |
Family income (per year) |
< 22,000 US | 127 (59.9) | 452 (42.9) | 2.01 (1.40–2.89) | <0.001 |
22,000–33,000 US | 38 (17.9) | 265 (25.2) | 1.03 (0.65–1.62) | 0.915 |
> 33,000 US | 47 (22.2) | 336 (31.9) | ref | |
Diagnosis, n (%) |
Nicotine use disorder | 41 (14.9) | 310 (24.5) | 0.54 (0.38–0.77) | 0.001 |
Alcohol use disorder | 61 (22.3) | 586 (46.4) | 0.33 (0.24–0.45) | <0.001 |
Anxiety disorder | 137 (51.3) | 412 (32.9) | 2.15 (1.65–2.81) | <0.001 |
Depressive disorder | 175 (64.6) | 225 (20.1) | 7.24 (5.45–9.62) | <0.001 |
Dysthymic disorder | 21 (9.3) | 36 (2.9) | 3.41 (1.95–5.97) | <0.001 |
Psychotic disorder | 9 (3.3) | 25 (2.0) | 1.69 (0.78–3.66) | 0.186 |
Somatoform disorder | 17 (6.6) | 85 (6.9) | 0.96 (0.56–1.65) | 0.884 |
Table
2 summarizes the associations between personality constructs and MHSU. After adjusting for age, gender, and economic status (Model 1), neuroticism (adjusted OR [AOR] = 1.30, 95% CI = 1.20–1.41) was positively associated with MHSU, and extraversion (AOR = 0.92, 95% CI = 0.86–0.99) and agreeableness (AOR = 0.89, 95% CI = 0.82–0.97) were negatively associated with MHSU. After further adjustment for DSM-IV psychiatric disorder in addition to age, gender, and economic status (Model 2), both neuroticism (AOR = 1.22, 95% CI = 1.10–1.34) and openness (AOR = 1.10, 95% CI = 1.00–1.22) were positively, and agreeableness (AOR = 0.89, 95% CI = 0.80–0.99) was negatively associated with MHSU.
Table 2
Multivariate analyses of personality variables and mental health utilization
Extraversion | 0.92 (0.86–0.99) | 0.023 | 0.98 (0.90–1.06) | 0.976 |
Agreeableness | 0.89 (0.82–0.97) | 0.009 | 0.89 (0.80–0.99) | 0.038 |
Conscientiousness | 0.98 (0.90–1.06) | 0.615 | 1.04 (0.94–1.15) | 0.437 |
Neuroticism | 1.30 (1.20–1.41) | <0.001 | 1.22 (1.10–1.34) | <0.001 |
Openness | 1.06 (0.98–1.15) | 0.140 | 1.10 (1.00–1.22) | 0.048 |
Discussion
In the KECA data, only 17.8% of patients with mental disorders reported ever using mental health services. Low use of mental health services among Koreans may be due to lack of mental health literacy and self-will to deal with mental illness by themselves [
34]. Our results indicate that personality traits are closely associated with mental service utilization. Neuroticism, openness, and agreeableness were significantly associated with MHSU, after controlling for demographic and psychiatric features.
When comparing mental health service users and non-users, female gender, older age, and low income were related to the increased MHSU, consistent with prior findings from other national samples [
2]. With regard to MHSU by psychiatric diagnoses, patients with nicotine use disorder and alcohol use disorder were less likely to seek help, while patients with internalizing disorders, including anxiety, depressive, and dysthymic disorder, were more likely to seek help. This is compatible with prior findings that only a few, 2.4% of, Chinese people with lifetime alcohol dependence sought professional treatment in Chinese [
35]. According to the self-medication hypothesis, patients with substance use disorder often suffer with their emotional distress and tend to use substances to relieve and control their painful feelings [
36]. Therefore, in our data, those with substance use disorders might have depended more on self-medication practices than on professional treatment for their emotional difficulties. Particularly, Koreans may not consider alcohol or nicotine use disorder as psychiatric problem, and therefore, may be unwilling to seek professional help, as found among Chinese population [
35]. Accordingly, patients who self-medicate with substance for emotional distress may be less willing to seek and receive professional service for both their emotional and behavioral symptoms.
The association between neuroticism and MHSU found in our data has already been established in prior studies [
9,
15,
37]. In previous results, neuroticism was related to MHSU [
9] and increased number of mental health visits [
15] in general population. In addition, among people with a subclinical depression, a greater level of neuroticism was associated with a greater tendency to perceive need for psychological care [
37]. Given that neuroticism predicts more severe and impaired depressive symptoms [
13], people who are high on neuroticism may actually experience more distressing symptoms which lead to greater professional help seeking. As neuroticism is associated with the lower problem-solving abilities [
38] and difficulty in coping with negative emotions [
39], it is also possible that people with high neuroticism may be less confident that they are able to solve their problems on their own by mobilizing their own supports. For instance, a neurotic patient may experience more difficulties handling his or her psychiatric symptoms, feeling overwhelmed, and therefore tend to be more dependent on professionals’ help.
In our data, openness to experience was significantly related to MHSU after controlling for psychiatric disorders. The results are inconsistent with the results of prior research failing to identify a significant relationship between openness and MHSU [
9,
16]. However, a recent study found that openness was associated with increased active coping style and decreased avoidance to problems, and was also related to mental health care consumption for early psychotic symptoms [
17]. Also, college students with lower openness to emotional experience and expression reported more negative attitudes toward seeking help for mental problems [
40]. Taken together, openness may help a person to be less resistant to seek psychological help, particularly in Korea, where people are often pressured to inhibit their feelings and avoid shame related to mental illness [
41].
An inverse association between agreeableness and MHSU was found in our data. There might be several possible explanations of the inverse association found in our data. One possibility is that the actual need for professional help might be lower among patients with high agreeableness than those with low agreeableness. For instance, patients with high agreeableness seem to have better social support [
17,
42] and thus might be able to cope better with emotional difficulties without seeking professional help. Given the relevance of agreeableness to altruistic and sympathetic attitude and desire of giving help to help others [
43‐
45], an alternative hypothesis may be that highly agreeable individuals focus less on their own difficulties than on those of others, and so will not actively seek for treatment despite their real need for professional help. Scholte-Stalenhoef et al. [
17] found that individuals with high agreeableness were less likely to express their emotions, which was related to a decreased active coping style. Lastly, individuals with high agreeableness might be more sensitive to being negatively evaluated by others and have concerns for how others would view their mental difficulties or use of mental health service. For instance, agreeableness was found to be significantly correlated with the tendency to tailor one’s response to impress others (i.e., impression management), which might be related to the desire to preserve positive relations with others [
46]. Considering the negative stigma toward mental illness among Asians [
19], those with agreeableness traits might be more inhibited to present their difficulty to others. However, the data from this study cannot offer a clear account of this mechanism.
This study has several limitations. The cross-sectional design prevented investigation of the causal relationship between personality traits and MHSU. Second, we used lifetime MHSU rather than MHSU during a shorter period of time (e.g., prior 12 months). This may have lead to underestimation of MHSU due to recall bias over a longer duration. Finally, we only included community-dwelling individuals and not patients in institutional settings, which may have lead to the under-reporting of MHSU.