Research report
What depressive symptoms are associated with the use of care services?: Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

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Abstract

Background: Depression is generally regarded as a serious, incapacitating illness. Although effective treatment strategies are available, timely recognition remains a stumbling block. We investigated the rates of health service uptake among depressed people and the specific depressive symptoms associated with service use, after adjustment for other illness characteristics and sociodemographic variables. Methods: In a representative sample (n=7076) of the Dutch adult population, we identified 1572 subjects with lifetime major or minor depression, using the Composite International Diagnostic Interview. Results: The majority (73%) of subjects with depression had sought specialised mental health care, or to a lesser extent primary care. As expected, those with more severe (vegetative), complex (anxiety-comorbid) or dangerous symptoms (suicidal ideation) were more likely to be treated in the specialised mental health sector. However, subjects with comorbid substance use dependence were less likely to receive care, especially primary care, and those with more education were more likely to receive specialised care, even after adjustment for illness characteristics. Limitations: The use of lifetime measures of depression and service use may have introduced slight recall bias, but it made the assessments less vulnerable to selection bias for chronic cases and to misclassification of subjects with some lifetime treatment experience. Conclusions: Although care for people with depression is readily accessible in the Netherlands, people with less education and people with comorbid substance use dependence remain unnecessarily out of reach of the care services. Primary care services need to be strengthened to enable the broad-scale application of stepped-care strategies.

Introduction

Depression is an incapacitating illness that is widespread in the general population (Bijl and Ravelli, 2000a). Major depression is one of the conditions with the heaviest burden of illness, comparable to that of lung cancer or stroke as expressed in terms of disability-adjusted life years (DALYs; van der Maas and Kramers, 1997). Several different population studies have shown that many people with major depression do not receive help for their illness (Robins et al., 1991, Katz et al., 1997). In the United States, for example, Regier et al. (1993) have estimated that only 38% of the subjects with a diagnosis of affective disorder in the past year had used mental health services for that illness during that period. Such findings have prompted initiatives to hasten the recognition of depression, either by the depressed people themselves or by care providers (especially general practitioners). Examples of such initiatives are health education campaigns, professional development courses for GPs and the creation of guidelines for depression.

To effectively organise such activities, we need more information about which symptoms of depression are linked to the use of primary care (mainly after self-referral) and to specialised mental health care (after referral by a GP), and also information about why certain sociodemographic groups remain outside the reach of care services. A number of different studies have shown that females (O’Neil et al., 1984), older adults (O’Neil et al., 1984, Bucholz and Robins, 1987, Olfson and Klerman, 1992, Kendler, 1995) and better-educated people (Olfson and Klerman, 1992, Kendler, 1995) are more likely to seek help for depression. These studies did not investigate, however, in which sectors the help was obtained and what processes were involved among patients and care providers (Goldberg and Huxley, 1980, Goldberg and Huxley, 1992). Are better-educated people more likely than others to contact primary care on their own initiative, do GPs refer them more readily to specialised mental health services, are the latter more likely to take them into treatment, and/or do they receive care on the basis of less severe symptoms? Understanding such potential selection processes in service use could be helpful in clarifying (1) whether care services are functioning properly (for example, whether care for mental health problems is reaching the people with the most serious symptomatologies, rather than those with less severe symptoms but belonging to particular sociodemographic groups); and, by implication, (2) how the rate of detection and treatment of depression can be improved.

Using data from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), we will address here two questions in particular: (1) what percentage of the people with lifetime major or minor depression have used care services for mental health problems during their lives, and (2) which depressive symptoms are associated with service use, after adjustment for other illness characteristics and sociodemographic variables. Since care for mental health problems is basically accessible to all residents of the Netherlands, help-seeking behaviour is probably less subject to sociodemographic factors. We hypothesise that those with more severe (vegetative symptoms), more complex (comorbidity with anxiety or substance use dependency) or more dangerous symptoms (recurrent thoughts of death) will be more likely to receive mental heath care. To examine whether the correlates of service use vary according to the sector in which help is sought, we address the research questions separately for primary care and specialised mental health care.

Section snippets

Sample

The data used for this study are part of the NEMESIS study, which assessed mental disorders in a representative sample of the Dutch population aged 18–64 years. NEMESIS applied a multistage, stratified, random sampling procedure of households (Bijl et al., 1998a, Bijl et al., 1998b). First, a sample was drawn of 90 Dutch municipalities, stratified on the basis of urbanicity and adequately distributed over the 12 Dutch provinces. The second step was to draw a sample of private households from

Description of the sample

The vast majority of the 1572 respondents with lifetime depression had experienced symptoms of ‘depressed mood’, ‘insomnia or hypersomnia’, and ‘diminished ability to think or concentrate’ (Table 1). A minority had experienced ‘psychomotor agitation or retardation’ when depressed.

The average age at onset of the first depressive episode was 30.5 years, with 50% of respondents having their first episode before age 30 and 75% before age 39. Nearly 45% had a co-occurring anxiety disorder. About 9%

Discussion

Investigations of this type are rare, and partly for that reason it is difficult to compare our results to those of other studies. Only the study by Galbaud du Fort et al. (1999) controlled simultaneously for the influence of depressive symptoms and comorbid mental disorders on treatment seeking, whilst also defining depression and service use in ways comparable to ours. Other studies investigated either the role of depressive symptoms (Bucholz and Robins, 1987, Dew et al., 1988, Dew et al.,

Acknowledgements

This research was supported by the Medical Sciences Department of the Netherlands Organization for Scientific Research (NWO).

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