Crossnational differences

Cross-national differences in filter permeability and service use are difficult to examine. Service organization plays an important role. For example, compared with south Manchester, in the United Kingdom, closer integration between community and inpatient psychiatric services in south Verona, Italy, resulted in a greater permeability of the filter between inpatient and community care, as evidenced by higher hospital admission rates and shorter lengths of stay. Conversely, greater permeability of the general practitioner referral filter in south Manchester resulted in more referrals, and therefore higher treated incidence and prevalence rates of psychiatric disorder.(43) Similarly, compared with the more institution-based system in Groningen, in The Netherlands, the south Verona community-based system provided for a higher degree of continuity of care across services for patients with schizophrenia. (44)

Because of convergence in methodology, fascinating material on cross-national differences in the dynamic balance between psychological distress, need for care, and actual treatment received is now available from large prevalence surveys of representative samples in different countries. Comparative data using similar instruments measuring mental health and service use are available from three population studies of 5000 to 7000 individuals in three countries. In the United States and Ontario, Canada, samples representative of all non-institutionalized individuals aged 18 to 54 years were examined using the Composite International Diagnostic Interview (CIDI) in 1990 (United States National Comorbidity Survey and the Mental Health Supplement of the Ontario Health Study), and samples of people aged 18 to 64 years in The Netherlands were examined in 1996 (Nemesis Study).(4 46 and 47) There were few differences in the number of individuals with a single diagnosis in the three countries. However, the simultaneous presence of more than one traditional diagnostic label (comorbidity) is associated with a poorer prognosis, and as such can be considered as a measure of severity of the underlying condition. The rate of comorbid, more severe disorders was higher in the United States than in Ontario and The Netherlands (Table..!.). This difference persisted after adjustment for age, sex, marital status, education, family income, and degree of urbanization.(45) These findings therefore suggest that there may be real differences between countries in the rate of severe disorder, which can be most readily explained in terms of differences in the prevalence of environmental risk factors.

Table 1 Prevalence of CIDI disorder and service use in three countries

The three studies show that help-seeking rates among individuals with a diagnosable disorder also vary widely. The contact rate with any type of formal or informal service was lowest in the United States (33.9 per cent) and not far from twice as high in The Netherlands (56.7 per cent) ( Table ! ). Among individuals with a diagnosable disorder, ambulatory service use in the general medical sector was much higher in Ontario and The Netherlands than in the United States, especially among those with more severe comorbid disorders. Individuals in the United States with more severe disorders were less likely to use services in the health-care sector as a whole, but if treatment from self-help and other sources is included the difference between Ontario and Nemesis on the one hand, and the United States on the other, is attenuated. This suggests that low permeability of the primary care access and primary care referral filters in the United States may lead to increased use of non-professional services to fill the gap.

Table..!. shows that the higher the contact rates with professional services of individuals with a Composite International Diagnostic Interview diagnosis, the lower the number of individuals who were not using professional services but felt they were in need of such help (level of unmet need) ( Table 1). Such differences in the population level of unmet need are important from the point of view of public health. For example, if 90 per cent in a population of 200 million are non-users of professional services for mental ealth problems, than a difference between 8.4 per cent (United States) and 3.8 per cent (The Netherlands) in perceived need is a difference of 9.2 million individuals.

The substantial differences in mental health care provided by the general practitioner is likely to have an equally substantive impact on the likelihood of receiving appropriate management. Thus, the proportion of patients with major depression as defined in DSM-IIIR in the previous 12 months who received appropriate medication management, defined as a combination of antidepressant medication use and four or more visits to any health-care provider within the previous 12 months, was much higher in Ontario (14.9 per cent) than in the United States (7.3 per cent). This difference was especially marked for the lowest income groups in the two countries. Individuals in the lowest income groups in the United States were found to be 7.5 times less likely to make contact with either general or specialty health-care providers than their peers in Ontario. For the highest income groups, however, contact rates differed only by a factor 2.1. (48) These data suggest that economic barriers play an important role in determining the permeability of the filters on the pathway to care. In the United Kingdom OPCS Survey of Psychiatric Morbidity, 16 per cent of patients with a depressive episode in the past week according to the Revised Clinical Interview Schedule were current users of antidepressant medication.'49ยป

Because the majority of the population does not have a mental disorder, even a small degree of service use by this large segment of the population will take up a considerable part of the total capacity of mental health services. Thus, Katz et al.'(50) noted that because of the relatively high rates of perceived need for care and help-seeking among individuals without a Composite International Diagnostic Interview diagnosis in the United States, total mental health outpatient service use was higher in that country than in Ontario. Although diagnosis is only an imperfect indicator of need for care, the results nevertheless suggest that the mismatch between need and care in the population is greater in the United States than in Ontario.

A long-standing debate exists whether and how financing of mental health care can be used to maximize the fit between need and care in the population. A frequently expressed concern is that universal coverage will lead to an increase of people with little need using services of unproven value. The opposite argument, however, is that limitations in coverage will result in service use that is poorly matched to need. Although it is thought that differences in type of insurance system have an impact on demand and utilization of mental health services,(51 systematic comparisons between countries have been lacking. The systems of coverage in the United States, Canada, and The Netherlands are different in many respects. In Ontario, universal and relatively comprehensive coverage for mental health services exists, with no or minimal limits on inpatient stays or outpatient visits for mental health services, and minimal patient cost sharing. In The Netherlands, almost all mental health care is covered under the Exceptional Medical Expenses Act, and is available to the entire population. A comprehensive range of public services exists, with few supply-side controls. In the United States, around 16 per cent of the population is uninsured, and even for the insured mental health coverage is increasingly limited. Although the public health system provides mental health care at little or no cost to the poor and the uninsured, supply-side controls severely and increasingly limit access. Therefore, the results of the comparisons between the three countries do not support the frequently expressed reservation that expansion of insurance coverage for mental health disorders results in an increase in unnecessary use of services. Of the three countries considered, those with broad mental health coverage actually treated a similar number or more people with severe mental illness, but less people who never had a history of mental illness.

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