Socioeconomic factors and use of psychotherapy in common mental disorders predisposing to disability pension

Disability to work due to mental disorders is growing, and increasing costs due to health care expenditure and lost working years are a concern in high-income countries (HICs) [1, 2]. Common mental disorders (CMDs) including depressive and anxiety disorders [3] are highly prevalent globally [4] and major causes of disability pensions (DPs) [5]. The World Health Organization’s (WHO) estimate of the proportion of the global population with depression is 4.4% and with anxiety 3.6% [3]. In Finland, mental disorders are the most common reason for DPs (53%, 103,000 persons in 2019), and depression is the most common mental disorder [6].

Socioeconomic status (SES) is often defined by the factors: income, education, and occupation, to reflect a person’s social, material, and psychological resources [7, 8]. Low SES is associated with poorer mental health [7, 9] and higher work disability due to mental disorders [8, 10]. People with lower SES, especially lower education, tend to use mental health services less willingly than people with higher SES [11‐13], even though the need may be higher [7, 9].

Psychotherapy is an evidence-based treatment for depression and anxiety disorders [14, 15] and is recommended solely or in combination with pharmacotherapy [16, 17]. Recent literature indicates that there is an association between SES and psychotherapy use, and it varies according to the service system, as shown in British [18] and French [19] survey studies and a German [20] register data study. The British survey study [18] found that higher levels of education, income, and occupational status were all associated with more frequent use of private psychotherapy, when payment by the client was 40–100 GBP per visit. However, the British system offered also public psychotherapy which was used more frequently by people with lower income, education, and occupational status, even though public psychotherapy was not as readily available, due to a need for a referral and longer waiting times before receiving treatment. The French survey study [19] examined the role of life events, mental health status, and sociodemographic characteristics, including education, in determining psychotherapy use. The study included mainly middle-class, employed people with specific profession-based health insurance. Education was positively associated with psychotherapy use in different severities of psychiatric disorders, despite the fact that the study population was well-informed and with high-quality insurance cover [19]. In the German register study [20] of employed people with statutory health insurance, the positive associations of education and occupation with psychotherapy use were evident, whereas the association of income was rather weak, which was presumably attributable to the absence of financial barriers to outpatient psychotherapy in Germany. On the other hand, income-based inequities in psychotherapy use have been shown in Canada and Australia [21]. In both countries, the unmet need for psychotherapy was higher at low-income levels, even though the service systems differ. Canada has a two-tier system causing often higher psychotherapy costs for low-income people, whereas Australia has provided universally affordable psychotherapy since Better Access reform in 2006. The results indicated that income-based inequities in psychotherapy existed also in Australia, despite the reform. This was explained by an anti-stigma initiative in 2000 and better access to psychotherapy, when both demand and unmet need were supposedly increased especially among low-income Australians during the study period.

In Finland, rehabilitative psychotherapy may be partially compensated by the Social Insurance Institution (SII) to people whose ability to study or work is impaired due to a mental disorder, who have received at least 3 months of appropriate therapy, and to whom rehabilitative psychotherapy is considered necessary (based on a psychiatrist’s statement) to improve or support the ability to work or study [22, 23]. In addition to the SII compensation, which in 2020 was 57.60 euros per session [23], clients pay 30–70 euros per session out of their own pockets, depending on the therapist’s prices. Financial support for psychotherapy is available for up to 80 sessions per year and for up to a total of 200 sessions in 3 years [22]. The number of people using psychotherapy supported by the SII has grown from less than 10,000 in 2005 to over 50,000 in 2019 [24]. One notable reason for this increase is that rehabilitative psychotherapy was changed from being discretionary to mandatory in 2011, hence making its use no longer dependent on the SII budget, but on the need of the applicant [25]. Although the supply of psychotherapy was made less restricted, a shortage of psychotherapists remains, and it may take several months for a patient to find a psychotherapist. In addition to psychotherapy compensated by the SII, there is some psychotherapy for which patients pay entirely out of their own pockets, or in rarer cases is paid for by hospital districts as medical rehabilitation for patients, not within the scope of the services provided by the SII [22].

The present register study is part of the RETIRE research project, which studies the risk factors for DPs granted on grounds of mental health [26]. We aim to examine the socioeconomic equality of the Finnish service system in targeting psychotherapy at CMD patients prior to a temporary or permanent DP, and their comparison group. We hypothesise that psychotherapy use is lower in low SES groups, mostly due to financial barriers. Furthermore, we hypothesise that socioeconomic disparities in psychotherapy use are smaller among CMD patients approaching DP (CMD + DP group) than in the comparison group, because people in higher SES have more probably seeked for rehabilitative psychotherapy already at earlier stages of their mental health condition due to better-resourced occupational health services and higher mental health literacy [12, 22]. Furthermore, in the CMD + DP group, the need for rehabilitative psychotherapy is relatively urgent, and the health care system has to offer all the feasible treatment and rehabilitation measures, before the justification of DP. In addition, sociodemographic factors, age, gender, and family type are studied because of their assumed importance in explaining mental health [4, 27, 28] and help-seeking [11]. The aim of the present study is to complement the current research literature on the role of SES factors in psychotherapy use, in the context of a Nordic welfare state.

We found considerable socioeconomic differences in psychotherapy use in our comprehensive national-level data. We studied the common mental disorder (CMD) patients on the verge of disability pension (DP), when, at the latest, rehabilitation services should be in maximal use. Lower socioeconomic status (SES) was associated negatively with psychotherapy use according to all factors: income, education, and occupation. To the best of our knowledge, this was the first study, which specifically focused on people on the verge of DP and included all SES groups, regardless of their insurance or employment status. In addition to our primary hypothesis, older age and male gender were negatively associated with psychotherapy use. Our study findings corroborate those reported in earlier research [18‐20] in other HICs. Unlike we hypothesized, socioeconomic disparities in psychotherapy use were not any smaller in the CMD + DP group than in the comparison group, which implies that disparities are present even with an urgent need for services.

Education showed a positive association with psychotherapy use in both groups, which is in line with earlier research [18‐20, 32]. One explanation is that among people with lower levels of education, mental health literacy is lower and illness stigma is higher [12], which makes acceptance and help-seeking more complicated [33, 34]. Finding a therapist requires time and effort, which may be compromised among people with low SES, due to low MHL [12] and constrained living and working conditions [34]. Considering occupation, a pronounced gap in psychotherapy use among blue-collar workers may be linked to lower MHL due to lower levels of education [12] which hampers help-seeking and reduces willingness to spend money on psychotherapy. Furthermore, alcohol use disorder is among the most prevalent mental disorders among working-aged Finnish people, and blue-collar workers are at higher risk [7]. This co-morbidity may also prevent the treatment of CMDs.

Unemployed people attended psychotherapy notably less than the average in the CMD + DP group, but not in the comparison group. Unemployed includes both the temporary and the long-term unemployed. In Finland, two-thirds of long-term unemployed have health conditions that would render them eligible for a DP, half of them due to depression [35]. In our study, unemployed people with prolonged CMDs may have received rehabilitative interventions years before, outside the timeframe of our study, or they have become marginalized from services. Health services are provided in public, private, and occupational health care in Finland. Unemployed people have no access to occupational health care, which is usually free of charge for medical consultations and can often provide more preventive and early mental health interventions than municipal primary health care [22]. Personal factors like poor awareness of one’s own condition and feeling stigma may prevent help-seeking by unemployed people [36]. Also system-induced factors like miscommunication with professionals [36], financial barriers and lack of timely interventions may hinder unemployed people from obtaining the psychotherapy they need. In a previous RETIRE study we found no clear association for the regional number of psychotherapy recipients with regional all mental disorder DP risk [37]. This may indicate that psychotherapy is not successfully focused on people in the highest DP risk, which this study supports.

Income was positively associated with psychotherapy use in the highest and middle-higher (> 25,931 e) income categories among the CMD patients approaching DP when the reference was the lowest category. No corresponding association was found in the comparison group, presumably because people with lower SES have a higher prevalence of CMDs [7, 9] and correspondingly higher need for psychotherapy. Income-based unequal access to psychotherapy has also been reported in the UK [18] regarding private but not publicly provided psychotherapy, in Germany [20] to a minor extent because of the absence of financial barriers, and in Canada [21] with a two-tier system, in which psychological services are mostly to be paid for or are employment-based benefits, whereas the costs of medical consultations are fully covered by public health insurance, which resembles the Finnish system. In Finland, financial barriers to psychotherapy exist, despite partial reimbursement by the SII [22]. Therefore, we expected income to have a higher association with psychotherapy use than it had. Instead, education was one of the three interlinked SES factors most evidently associated with psychotherapy use.

This study also revealed sociodemographic inequalities in psychotherapy use. Older age was associated with less frequent psychotherapy use. This is in line with earlier research [38], even though the effect of psychotherapy for depression is not known to be any lower in older age groups [39]. Psychotherapy is offered well for young age groups and students, but many lost working years could be saved with more extensive rehabilitation for older working-age people with CMDs.

After adjustments, family status was associated with psychotherapy use only in the comparison group; people living alone attended more psychotherapy than did those living with a partner or children. CMD prevalence is higher among people living alone, which is partly explained by lack of social support, unemployment, and alcohol consumption [28]. Differences in CMD prevalence most probably explain the result in the comparison group.

Our study revealed a considerable gender difference; males attended psychotherapy decidedly less than females, which is in line with the literature [19, 32, 40]. The difference was greater in the comparison group, which is partly explained by the higher prevalence of depression among females [41], thus creating a greater need for psychotherapy. Excessive alcohol consumption especially among Finnish males [42] may inhibit recognition of CMDs, as well as help-seeking and rehabilitation for them. Males’ reluctance to seek help for mental health concerns has also been explained by cultural expectations, structural barriers, and unappealing service environments [40, 43]. Increasing awareness of mental health issues and reducing stigma in general could redefine acceptable ways to treat mental illnesses and lower the threshold for help-seeking.

We found evidence of a complex interplay of socioeconomic and sociodemographic factors contributing to differences in obtaining access to reimbursed psychotherapy. The reasons for this disparity are presumably diverse. System-based factors widening the socioeconomic disparities in mental health merit further study.