Inequality and inequity in use of mental health services

Epidemiological studies of mental illness have repeatedly shown an unequal distribution of illness among individuals in the community, among other things associated with socioeconomic and sociodemographic characteristics of the populations studied (1, 2). Lower social class and worse socioeconomic status in terms of finances, education and employment have been associated with higher rates of mental illness. Whether this should primarily be interpreted in terms of social causation or social consequences is still a topic of discussion. In a similar way the use of mental health services has been shown to be unequally distributed, insofar as a small proportion of patients use a large proportion of resources allocated to services. These inequalities have been related to sociodemographic factors such as living alone and unemployment, which in some studies have predicted a higher utilization of services (3). Gender differences have also been noted, albeit more seldom, and if so male sex has been associated with more heavy use of services. The clinical characteristic most often associated with high utilization has been a psychosis diagnosis. It is also noteworthy that studies of service use seldom have been linked to outcome of treatment in order to enable analyses of efficacy or effectiveness of service use. Studies of pathways to specialist psychiatric services, using the filter model proposed by Goldberg and Huxley (4), assume that a majority of patients are referred from general practitioners (GPs) to specialist services. However, the specific pathways patients may take are strongly influenced by a number of factors such as health-seeking behaviour and restrictions related to referral procedures (5). It is also affected by the relationship between specialist services and the surrounding health care system, and furthermore influenced by the resources allocated, availability and accessibility of the psychiatric specialist services (6). A WHO multicenter study on pathways to psychiatric care found that pathways to services well provided with staff was dominated by referrals from GPs and to a less extent from hospital doctors (7). Services with relatively fewer resources showed a greater variety of pathways. There has also been a notable urban/rural difference in pathways, insofar as rural areas are dominated by GP referrals, whereas in urban areas referrals from medical specialists or a direct contact with the psychiatric service are more frequent (8). A major question in this context is what are the causes of the inequalities rooted in socioeconomic status of the clients, and if these also point to an unfairness or inequity in service use both in terms of accesses to service content and outcome of treatment. The scientific documentation in this field is rather scarce and two articles in this issue of Acta Psychiatrica Scandinavica aim to enlighten this issue (9, 10). As evident from epidemiological general population-based studies the analysis of this issue is not straightforward. A large number of factors may influence service use, some of which are characteristic of the individual and the illness and others are more related to characteristics of the services. A very central feature in efforts to establish the relationship between, as in the papers of the present issue, aspects of socioeconomic status and service use and outcome of treatment is to have an adequate design enabling control over proxy variables and variables confounding the presumptive relationship. Among important patient characteristics to consider are differences in individual help-seeking behaviour, ethnical differences, individual treatment preferences, acceptability of services and severity of illness, which all may distort inferences of the relationship between socioeconomic status and service use. Among service characteristics it is essential, at least in multicenter studies or comparative studies, to control for differences in availability of resources and treatment options, and accessibility to services in terms of time, procedure and geography. A matter of greatest importance is whether inequalities in health and health care use are associated with inequities in health care use. The latter is, however, not inevitable. Inequities in health care use are a matter of social policy and public health policy, which goes far beyond inequalities in the use of services. Health equity within the field of mental health is a multidimensional concept including concerns about achievement of health and the individual capability of achieving this, and not merely the distribution of health care (11). It is also associated with matters of fairness and non-discrimination in the delivery of health care and requires that concerns about health are integrated in issues of social justice and equity. A general conclusion is that it is important to distinguish between inequalities and inequities in mental health and in the use of mental health services. They might be related but refer to quite different scientific and policy issues.