Main findings
This study is unique as it, to the best of our knowledge, is the first to examine the association between MH screening and both subsequent initiation or cessation of mental healthcare. We have described the major mental healthcare trajectories after a population-based MH screening with feedback to the GP on individual screening results. Reporting of poor MH status to the GP was associated with initiation of mental healthcare, whereas reporting of good MH status was associated with cessation of existing mental healthcare.
Follow-up support after health check
Only one in three participants detected with poor MH at the health check had a follow-up health check consultation with the GP, however, nearly half of participants with poor MH received some kind of MH support from the public healthcare system. This difference may have two explanations. First, it is possible that the number of follow-up health check consultation with the GP was underestimated. If the participant made an appointment for a normal consultation rather than a Check Your Health-consultation, the GP may not have recorded the consultation as a follow-up health check consultation. Second, the GP may be aware of the participant’s MH problems, independently of receiving feedback on the MH screening result from the health check.
Initiation of mental healthcare
The initiation of mental healthcare that took place within the follow-up period, was mainly performed within the first 6 months after the MH screening, and the mental healthcare was primarily provided by the GP. Contacts to psychologists and psychiatrists were mainly taken 6–12 months after the MH screening. Possible explanations could be that GPs seek to handle the patient’s MH problems first. If the MH problem does not improve, the GP may refer to secondary mental healthcare. Moreover, waiting time for appointments with specialist mental healthcare providers may contribute to the observed results [
24]. The time relation indicates that the mental healthcare provided is associated with the MH screening and the feedback to the GP of the individual screening results. However, for three in four participants with poor MH who did not receive mental healthcare at baseline, no initiation of any mental healthcare was seen during the one-year follow-up. This result was surprising because most of them had visited their GP (for any reason) within the same period. As we had no information on the content of the consultations, we cannot know how many actually did have some kind of (unregistered) psychological support by the GP. Explanations for the low uptake of mental healthcare may be the stigma associated with MH problems [
25] or the individual’s wish to handle the problems by themselves [
26]. Another explanation for the low proportion of initiated mental healthcare could be that GPs have too few resources to handle complex health issues, such as MH problems, which often coexist with physical diseases [
27]. As only 10–15 min are available per consultation, the GP may rather address the physical problems [
28]. Furthermore, the low rate of contacts to psychologists may be due to out-of-pocket payment requirements for psychological appointments in Denmark. Removing the financial barrier may be a means to improve the access to and benefit from psychological treatment, as seen in the Improved Access to Psychological Treatment (IAPT) initiative in the UK National Health Service [
29].
A recent Dutch study by Gidding et al., the PsyScan study, found somewhat similar results on several other parameters [
7]. They used a different screening tool than the one used in the
Check Your Health programme, but they found the same proportion of participants with positive screening results who received psychotropic medication (37%) at one-year of follow-up as we did (38%). Likewise, Gidding et al. identified a similar proportion of referrals to psychiatrists (12%) as we did in our study (15%). However, they found a much higher proportion of referrals to psychologists (17% vs. 8% in our study). An explanation for the observed difference could be that there is a substantial user fee for psychologist consultations in Denmark, whereas such consultations are largely free of charge in the Netherlands [
30]. Gidding et al. further compared healthcare trajectories with a control group, who was identified only on the basis of the GP’s suspicion of psychological problems. They found that the screening-detected individuals had statistically insignificant higher odds of getting a referral to a psychologist or psychiatrist, but no increased odds of being prescribed psychotropic medication. However, the authors did not succeed in recruiting the calculated number of participants, and their study may therefore be under-powered to demonstrate an effect.
A meta-analysis of studies comparing feedback on depression screening results to the GP with routine care found an increased rate of recognition and a tendency towards higher rates of intervention for depression [
8]. Thus, previous studies have found positive results on initiation of mental healthcare after screening, but the estimates are statistically insignificant. The studies included in the meta-analysis were markedly heterogeneous, and the authors are cautious not to draw any firm conclusions. Other studies suggest that systematic pre-screening of MH has the potential to increase the GP’s awareness of individuals in need of treatment [
31].
Cessation of mental healthcare
For nearly half of the participants who received mental healthcare at baseline and were rated to have good MH, the existing mental healthcare ceased within the follow-up period in the present study. The largest proportion ceased within the first 3 months after the MH screening, and only a marginal proportion ceased after 6 months. This could indicate that the GPs responded to the feedback on the participant’s good MH status. Possible reasons for continuing mental healthcare among the other half of participants with good MH are manifold: the GP may not have noticed the feedback in the participant’s electronic health record, or the participant may still need mental healthcare (for example patients with chronic or recurrent episodes of mental disorders for whom long-term use is advised) [
32]. GPs should regularly re-evaluate the patients who receive psychotropic medication [
32]. A post-hoc subgroup analysis revealed that among those with good MH who were prescribed psychotropic medication at baseline, the GPs had seen nearly all (94% (95% CI: 89–98)) at least once within the follow-up period. Thus, the GPs may have seen the screening results. However, certain reservations should be made as we had no access to information on the content of consultations. Thus, we do not know if MH was the subject of the consultation.
Previous studies have indicated that overtreatment is mainly explained by prolonged treatment rather than non-optimal treatment [
33]. In a Dutch study, Eveleigh et al. assessed the effectiveness of a tailored recommendation to cease antidepressant medication [
9]. They found that half of patients complied with the advice to stop their antidepressant treatment. However, only 6% succeeded, defined as ‘no antidepressant use during the preceding 6 months and the absence of a depressive or anxiety disorder during the one year follow up’ [
9]. There are different possible explanations for the lower success rates in the Dutch study compared to ours. Eveleigh et al. focused solely on cessation of antidepressant medication among over-treated long-term antidepressant users, whereas we concentrated on any mental healthcare among participants with good MH screening results. Hence, short-term users of psychotropic medication formed part of our population. Cessation of psychotropic medication among long-term users is a well-known challenge [
34], which may explain the low success rate in the Dutch study. In our study, some short-term users may have stopped their medical treatment due to side effects or lack of effect, which may explain part of the cessation in our study.
Strengths and limitations
A major strength of the present large-scale population-based study is that it was implemented in the existing healthcare system and thus reflects realistic healthcare trajectories in Denmark and in other countries with a similar healthcare system and similar commissioning structures. We used national registers as a source of information on mental healthcare. Thus, we achieved virtually complete follow-up on nearly all participants (99.9%). Furthermore, registers are considered a better source to inform on utilisation of MH services than surveys [
35]. However, we focused only on individuals aged 30–49 years, thus the results may not be valid for other age ranges.
To the best of our knowledge, our study is the first to evaluate the association between MCS score from the SF-12 and subsequent mental healthcare trajectories. The MCS score is a commonly used measure of generic MH in epidemiological research [
15]. Moreover, it has been suggested as a useful screening tool for common mental disorders in the general population [
17]. The MCS has been validated against depressive and anxiety disorders [
17‐
19], and a score of < 36 (near our definition of poor MH at an MCS score of ≤35.76) has been shown to have a sensitivity of 0.62 for any depressive disorder and of 0.73 for generalised anxiety disorder. Furthermore, the probability of not having a depressive disorder at an MSC score of > 48 (which is close to our definition of good MH at an MCS score of > 48.26) is 99% with a prevalence of 3.0% [
18]. Moreover, a cut-point of ≤36 seems to include individuals with severe psychological symptoms and individuals with moderate to severe disability [
19,
36]. Therefore, we believe that the cut-offs for poor and good MH are reasonable for raising the GP’s awareness of their patients’ need of mental healthcare.
A limitation was that we had no information on informal or unrecorded mental healthcare, such as unrecorded psychological support by GPs, counselling outside the health services, or consultations with psychologists covered by private health insurance or self-financed consultations without referral from the GP.
We defined psychometric testing by the GP as a type of MH support. We are well aware that this is not a treatment by itself. However, we consider the use of psychometric tests in general practice as a way of taking action on MH status, and therefore as an important indicator of the mental healthcare trajectories.
We defined cessation as no recorded mental healthcare in 6 months. However, it is not very likely that one stops taking the medication on the day when a prescription is redeemed at the pharmacy (which is the date registered in the DNPR). Hence, we have categorised some participants as having ceased the medication too early in proportion to the true date of cessation. Additionally, psychotropic medication should be gradually reduced rather than stopped abruptly [
37]. Thus, dose reductions that did not lead to full cessation within follow-up and unsuccessful attempts of cessation were not registered. Therefore, our estimate of individuals who had their psychotropic medication ceased is most likely an underestimation of GP action on the feedback on MH status.
Only participants with a risk profile from the health check were recommended a follow-up consultation with their GP. Therefore, cessation of mental healthcare among participants with good MH and no health risk factors was dependent on the participant’s own initiative to contact the GP or that the GP brought up the issue at the next consultation. This may have reduced the potential to cease unnecessary MH treatment.
Although both initiation and cessation of mental healthcare seemed to be time related to the MH screening, we should not draw conclusions on the causality of the observed associations in this descriptive cohort study. We obtained the MH status only on the 51% of the invited population who participated in the MH screening. Hence, we were unable to compare their mental healthcare trajectories with those of non-participants. Therefore, randomised controlled trials are needed to further explore the causal effect of MH screening on initiation and cessation of mental healthcare.