Background
Methods
Information sources and search strategy
Eligibility criteria
Include | Exclude | |
---|---|---|
Participants | - Population-based studies, in which participants are randomly sampled from a sampling frame that can be reasonably expected to include the majority of the adult population - Studies in which CMD is measured and analyses are restricted to those who “screen positive” for CMD.a | - Any studies including people aged under 18 (unless these are presented separately in analyses) - Studies with exclusion criteria that would rule out a large proportion of the adult population (e.g. over-55 s only, people of a particular minority ethnic group only, women who have recently given birth) - Studies in which participants do not live in community settings (e.g. prisoners, inpatients, residents of elderly care homes) or are defined by their occupation (e.g. doctors, police officers, students) - Studies in which all participants have used health services for mental health reasons - Studies that combine people with CMD and those with other conditions and do not report results separately in analyses - Ecological level studies in which CMD is not controlled at the individual level (i.e. it’s not possible to tell whether the people using services are the same individuals who have CMD) - Studies that apply overly restrictive exclusion criteria for participants, e.g. focussed solely on individuals with a specific comorbid condition, or restricted to only specific ethnic groups |
Design | - Observational - Quantitative or qualitative comparison of treatment-seekers and non-treatment-seekers - Cross-sectional or longitudinal - Articles published in peer-reviewed journals only | - Reviews/commentaries/opinion pieces - Conference abstracts/dissertations/book chapters - Case studies that lack quantitative evaluation |
Outcomes | - Studies reporting on the use/non-use (as a binary variable) of formal, face-to-face health services (either specialist or non-specialist, public or private) for mental health reasons - Timeframe in which service use is measured must be clearly defined (e.g. past 12 months) | - Studies reporting on general health care use (i.e. including for reasons other than mental health problems) - Studies examining use of only one specific treatment type (e.g. antidepressant use only, counselling only) - Studies reporting on volume of treatment (i.e. number of visits to a treatment provider), adherence to treatment or quality of treatment - Studies reporting on rates of detection or referral - Studies reporting on theoretical access rather than actual use (e.g. insurance coverage, being registered with a clinic) - Studies reporting on the use of online or telephone-based services - Studies examining the use of informal care (e.g. friends/family/religious support) or complementary/alternative treatments (i.e. those provided outside of the formal health sector) - Studies reporting on willingness or intentions to use services, or recommendations for service use in case of experiencing CMD symptoms, with no measure of actual behaviour - Studies that report participation in screening as the outcome rather than active treatment-seeking or uptake of services post-screening |
Correlates | - Any factors that are correlated with the outcome of interest, including (but not limited to): • demographic factors • health status (e.g. severity/disability/comorbid conditions etc.) • distance/transport to services • insurance coverage • interventions • specific symptoms • behavioural/personality factors • neighbourhood characteristics • characteristics of the healthcare provider • health systems factors • stigma/attitudes towards services | - Studies reporting on the magnitude of the treatment gap, without any correlates of treatment-seeking - Studies that report predictors of service type (e.g. generalist vs. specialist, pharmacological vs. psychological) rather than any vs. no use - Studies reporting barriers and facilitators to the use of health services, without examining the association between these barriers and actual treatment-seeking behaviour |
Dates | Any year of publication | |
Region | Any country or region |
Study selection
Criterion | Definition | Example |
---|---|---|
Appropriate sampling strategy | Population-based sample using a sampling frame that can reasonably be assumed to include the majority of the non-institutionalised adult population. (Justification of sample size was not included in this criterion since none of the included studies justified their sample size with reference to the research questions addressed in this review.) |
Meets criterion:
Simple random sample of households chosen from a government list of residential addresses, then one resident aged > = 18 randomly chosen to participate.
Doesn’t meet criterion:
Males and females sampled through separate means (males at compulsory conscription, females at enrolment on the electoral register). |
Sample representative of target population | Sample representative of non-institutionalised adult population, with minimal exclusion criteria applied. |
Meets criterion:
All adults eligible in urban area where study was conducted. Sample representative of urban residents with regard to major socio-demographic factors tested.
Doesn’t meet criterion:
Participants excluded due to age, ethnicity, chronicity of symptoms, comorbid conditions etc. |
Appropriate measures used | Validated measure of CMD (either screening tool or diagnostic instrument), timeframe for health service utilisation limited and specified. |
Meets criterion:
CIDI, AUDADIS-IV, CIS-R, SPIKE, PHQ-9, GAD-7, DIS, Burnam depression screener 12 month help-seeking from health services for MH reasons
Doesn’t meet criterion:
Self-defined depression/anxiety, prior receipt of diagnosis Lifetime use of health services (due to limited accuracy of recall) |
Acceptable response rate | > 60% response rate for cross-sectional studies > 60% response rate and < 30% attrition rate for longitudinal studies |
Meets criterion:
> 60% response rate across all study sites, or across all major groups compared
Doesn’t meet criterion:
< 60% response rate overall, in some study sites, or for one gender |
Data extraction and synthesis
Evidence level | Criteria |
---|---|
Good evidence of an association | ≥75% of studies that investigated this factor report an association, of which ≥2 (using different datasets) are of good/excellent quality |
Good evidence of no association | < 25% of studies that investigated this factor report an association, of which ≥2 (using different datasets) are of good/excellent quality |
Inconsistent evidence | 25–75% of studies that investigated this factor report an association, of which ≥2 (using different datasets) are of good/excellent quality |
Poor quality evidence only | < 2 studies of good/excellent quality (using different datasets) investigated the association between this factor and treatment-seeking for CMD |
Not examined | No studies investigated the association between this factor and treatment-seeking for CMD |
Results
Search results
Factors associated with health service utilisation for CMD
Type | Factor | Summary of associations found | Evidence level | No. of studies | Relationship | No. of good quality studies | No. of longitudinal studies | Total sample size | Total number of studies from each region | No. of studies from LMIC | |
---|---|---|---|---|---|---|---|---|---|---|---|
Predisposing factors | |||||||||||
Demographic | Age | Hill-shaped relationship commonly reported, with highest use by middle-aged individuals and lower use by the young and the elderly | Inconsistent | 25 | Hill-shaped | 9 | 3 | 33,779 | 10 1 1 | N. America Australasia L. America | 1 |
Positive/Consistent with hill-shape | 2 | 2 | 3162 | 1 1 2 | Africa L. America Europe | 2 | |||||
Mixed | 0 | 1 | 1926 | 2 | Europe | 0 | |||||
Null | 4 | 0 | 6501 | 2 2 2 | Africa N. America Europe | 2 | |||||
Age of onset | Older age of onset associated with service use in some studies | Inconsistent | 3 | Positive | 2 | 1 | 14,640 | 2 | N. America | 0 | |
Other | 0 | 1 | 1572 | 1 | Europe | 0 | |||||
Gender | Female gender generally associated with greater service utilisation | Inconsistent | 29 | Positive (women) | 9 | 5 | 28,201 | 10 1 1 1 | N. America L. America Africa Europe | 1 | |
Other/mixed | 4 | 2 | 29,838 | 3 2 1 | N. America Africa Europe | 2 | |||||
Null | 5 | 2 | 6380 | 1 1 2 1 4 | Africa Asia N. America Australasia Europe | 1 | |||||
Negative (women) | 1 | 0 | 531 | 1 | L. America | 1 | |||||
Social structure | Ethnicity | Caucasian ethnicity commonly associated with greater use than other ethnic groups | Inconsistent | 23 | Positive (white) | 7 | 2 | 60,534 | 11 1 | N. America L. America | 1 |
Positive compared to some ethnicities only | 2 | 0 | 17,299 | 3 | N. America | 0 | |||||
Mixed | 4 | 1 | 36,558 | 5 1 | N. America South Africa | 1 | |||||
Null | 2 | 1 | 2658 | 2 1 | N. America Australasia | 0 | |||||
Immigration status | No clear pattern found | Inconsistent | 6 | Negative (born abroad) | 0 | 1 | 2026 | 1 | Europe | 0 | |
Null | 2 | 1 | 15,056 | 2 1 | N. America Australasia | 0 | |||||
Mixed | 0 | 0 | 7687 | 2 | N. America | 0 | |||||
Marital Status | Being married associated with lower service use in some studies | Inconsistent | 18 | Negative (married) | 5 | 2 | 10,367 | 5 1 1 | N. America Europe Australasia | 0 | |
Null | 5 | 1 | 17,493 | 1 2 2 2 | L. America Africa N. America Europe | 3 | |||||
Positive (married) | 1 | 1 | 337 | 1 | N. America | 0 | |||||
Mixed | 2 | 1 | 13,590 | 1 1 | N. America Europe | 0 | |||||
Education | Higher levels of education associated with greater service use in some studies | Inconsistent | 20 | Positive (higher) | 6 | 4 | 31,441 | 6 1 1 1 | N. America Europe L. America Africa | 2 | |
Null | 7 | 1 | 11,377 | 5 2 1 1 | N. America Europe Australasia Africa | 1 | |||||
Mixed | 0 | 1 | 2130 | 1 1 | N. America Europe | 0 | |||||
Personality | Conscientiousness | No clear pattern found | Poor | 1 | Positive | 0 | 1 | 354 | 1 | Europe | 0 |
Mastery | No clear pattern found | Poor | 1 | Mixed | 0 | 1 | 903 | 1 | Europe | 0 | |
Neuroticism | Inconsistent | 2 | Positive | 1 | 1 | 2005 | 1 | Australasia | 0 | ||
Null | 1 | 1 | 102 | 2 | Europe | 0 | |||||
Health beliefs | Prior use of services | Prior use associated with greater use | Good | 3 | Positive | 2 | 2 | 13,672 | 4 | N. America | 0 |
Null | 0 | 0 | 0 | 0 | 0 | ||||||
Stigma | No clear pattern found | Poor | 2 | Null | 0 | 0 | 102 | 1 | Europe | 0 | |
Mixed | 1 | 0 | 56 | 1 | Asia | 1 | |||||
Mental Health Literacy | Not investigated | 0 | N/A | 0 | 0 | 0 | 0 | ||||
Enabling factors | |||||||||||
Assets | Income/ wealth | Most studies did not find any association | Good – no association | 11 | Null | 5 | 0 | 7623 | 3 3 1 | N. America Africa Europe | 3 |
Positive | 1 | 0 | 7209 | 1 1 | N. America Asia | 1 | |||||
Mixed | 1 | 0 | 2510 | 2 | N. America | 0 | |||||
Employment | Being employed associated with lower use in some studies | Inconsistent | 8 | Negative (being employed) | 2 | 2 | 3452 | 2 2 | N. America Europe | 0 | |
Null | 3 | 0 | 3059 | 2 1 1 | Africa Europe Australasia | 2 | |||||
Social support | Greater social support linked to use in some studies | Poor | 5 | Positive | 0 | 1 | 661 | 1 1 | Europe Africa | 1 | |
Null | 1 | 1 | 1275 | 2 1 | N. America Europe | 0 | |||||
Insurance | Having health insurance associated with use in some studies | Inconsistent | 7 | Positive | 2 | 1 | 10,393 | 4 | N. America | 0 | |
Null | 1 | 0 | 956 | 2 | N. America | 0 | |||||
Mixed | 0 | 0 | 558 | 1 | N. America | 0 | |||||
Need factors | |||||||||||
Perceived | Self-rated health/perceived need for care | Better self-rated health (/lower perceive need for care) associated with lower service use | Good | 8 | Negative | 2 | 2 | 2738 | 2 1 | N. America Europe | 0 |
Mixed or indirect | 2 | 0 | 2865 | 3 | N. America | 0 | |||||
Null | 0 | 1 | 491 | 1 1 | N. America Asia | 1 | |||||
Evaluated | Symptom severity | Greater severity commonly associated with service use | Inconsistent | 16 | Positive | 5 | 5 | 23,165 | 7 2 1 | N. America Europe Australasia | 0 |
Mixed | 1 | 0 | 298 | 1 | Europe | 0 | |||||
Null | 3 | 1 | 4052 | 2 2 1 | N. America Europe Asia | 1 | |||||
Chronicity/duration | Longer duration associated with service use | Good | 3 | Positive | 3 | 0 | 8603 | 2 1 | N. America Europe | 0 | |
Disability | Greater impairment associated with service use | Good | 8 | Positive | 3 | 1 | 4794 | 1 3 1 | N. America Europe Australasia | 0 | |
Mixed/borderline | 0 | 1 | 2199 | 2 1 | N. America Europe | 0 | |||||
Comorbid conditions – total | No clear pattern found | Poor | 4 | Null | 1 | 1 | 7565 | 1 1 1 | N. America Europe L. America | 1 | |
Non-psychiatric chronic conditions | No clear pattern found | Inconsistent | 14 | Positive | 3 | 2 | 17,455 | 3 1 1 | N. America Europe International | 1 (combined HIC/LMIC) | |
Negative | 1 | 0 | 220 | 1 | Europe | 0 | |||||
Mixed | 1 | 0 | 7460 | 1 1 | N. America Africa | 1 | |||||
Null | 5 | 1 | 4567 | 3 2 1 | Europe N. America Australasia | 0 | |||||
Psychiatric comorbidities (general) | Comorbid mental disorders (in general) associated with service use | Good | 6 | Positive | 5 | 3 | 6295 | 3 2 1 | N. America Europe Australasia | 0 | |
Comorbid SUD | No clear pattern found | Inconsistent | 8 | Positive | 3 | 1 | 24,189 | 3 | N. America | 0 | |
Negative | 1 | 1 | 1,1,56 | 2 | N. America | 0 | |||||
Mixed | 0 | 1 | 1572 | 1 | Europe | 0 | |||||
Null | 2 | 1 | 20,445 | 2 | N. America | 0 | |||||
Comorbid mood/anxiety disorders | Comorbid mood/anxiety disorders associated with service use | Good | 6 | Positive | 5 | 4 | 26,714 | 3 2 | N. America Europe | 0 | |
Null | 1 | 0 | 102 | 1 | Europe | 0 | |||||
Other comorbid mental disorders | No clear pattern found | Inconsistent | 3 | Mixed | 3 | 1 | 8719 | 3 | N. America | 0 | |
Panic symptoms | Panic symptoms associated with service use | Good | 6 | Positive | 5 | 2 | 26,350 | 4 1 | N. America Australasia | 0 | |
Negative | 0 | 0 | 558 | 1 | N. America | 0 | |||||
Suicidality | No clear pattern found | Inconsistent | 3 | Positive | 2 | 0 | 1646 | 1 1 | N. America Europe | 0 | |
Null | 1 | 1 | 2864 | 1 | N. America | 0 | |||||
Somatisation | No evidence of any association | Good – no | 2 | Null | 2 | 1 | 1566 | 2 | N. America | 0 | |
Other CMD symptoms | No clear pattern found | Inconsistent | 5 | Mixed | 2 | 1 | 15,941 | 3 2 | N. America Europe | 0 | |
Adverse childhood events | No clear pattern found | Poor | 4 | Positive | 0 | 2 | 1926 | 2 | Europe | 0 | |
Mixed | 1 | 1 | 1201 | 2 | Europe | 0 | |||||
Contextual factors | |||||||||||
Place of residence | Urban/rural residence | No evidence of any association | Good – no | 7 | Null | 6 | 1 | 16,677 | 3 2 1 1 | N. America Europe Australasia L. America | 1 |
Country | No clear pattern found | Inconsistent | 3 | Mixed | 2 | 0 | 4111 | 1 1 | N. America/Europe N. America/ Australasia | 0 | |
Null | 0 | 0 | 751 | 1 | N. America | 0 | |||||
Region (within-country) | No clear pattern found | Inconsistent | 3 | Positive | 1 | 1 | 7620 | 1 1 | N. America L. America | 1 | |
Null | 1 | 0 | 7153 | 1 | N. America | 0 | |||||
Health service factors | Service availability (perceived) | No clear pattern found | Poor | 1 | Positive | 0 | 1 | 435 | 1 | N. America | 0 |
Service accessibility | No clear pattern found | Poor | 1 | Null | 0 | 0 | 56 | 1 | Asia | 1 | |
Regular source of care | No clear pattern found | Poor | 2 | Mixed | 1 | 0 | 436 | 2 | N. America | 0 | |
Organisation of services (gatekeeper) | No clear pattern found | Poor | 1 | Negative | 1 | 0 | 1498 | 1 | N. America | 0 | |
Service capacity/waiting times/opening hours | Not investigated | 0 | N/A | 0 | 0 | 0 | 0 | ||||
Resources available | Not investigated | 0 | N/A | 0 | 0 | 0 | 0 | ||||
Healthcare policy | Not investigated | 0 | N/A | 0 | 0 | 0 | 0 | ||||
Quality of care | Not investigated | 0 | N/A | 0 | 0 | 0 | 0 | ||||
Social factors | Neighbourhood norms | Not investigated | 0 | N/A | 0 | 0 | 0 | 0 |