Abstract
Keywords
A behavioural model of health care utilization, such as that developed by Andersen and Newman [1], proposes that patterns of utilization of health services are related to individuals' needs for such services, their predisposition for using health services and enabling factors relating to both the individual (for example, level of education or income) and to the structure of the health-care system (for example, availability and accessibility of services). This perspective has been found to have relevance for predictors of utilization of mental health services by Australians [2]. However, these predictors relate only to whether or not services are used for mental health reasons and not to the type of help provided during the delivery of those services, a component recognized as important by Andersen and his collaborators in a later version of the model [3].
Types of mental health help
Any individual presenting with a mental health problem to a health professional may receive various types of health care. These include information about health problems and possible treatments, prescription of medication, counselling or psychotherapy, and practical advice. The type of help offered is likely to depend on variables relating to both the individual and the health practitioner, and the interaction occurring between these two players. Such variables will affect the individual's presentation of their problems and also the provider's assessment of those problems and selection of treatment of those problems.
Patient-related factors
An individual's presentation of a mental health problem will be associated with his or her understanding of that problem, and his or her ability to describe it to a health professional. Understanding of the problem will, in turn, be related to the individual's sociocultural conceptions of his or her difficulties and which symptoms are sufficiently distressing to warrant seeking formal help to relieve them [4]. Those with better understanding of mental disorder or previous experience of the problem may be more likely to present it clearly and may also be better able to specify the type of help they are seeking [5, 6]. Such requests may be more likely to be met by the health practitioner than those less clearly expressed. In a study of doctor–patient communication, patients with higher levels of education were found to receive more information about their illnesses from medical practitioners when compared with those of lower education, but with similar health problems [7]. Similarly, those with mental health problems who were more communicative and adept at obtaining what they wanted were more likely to receive mental health treatment, in particular, some form of psychological therapy [6]. On the other hand, those with little understanding of their problem and no previous experience of effective treatments for that problem may not realize what help is available and have no appreciation of the advantages and disadvantages of different types of help. Such patients are likely to rely entirely on the practitioner to select the type of health care that they might receive [8]. To the practitioner, such patients may appear diffident, and, lacking the psychological vocabulary to describe their problem well, may describe their symptoms only vaguely, with little awareness of the types of health treatment that could be considered [4, 7, 8].
Factors relating to the health practitioner
Advice and treatment offered will also be affected by various factors associated with the practitioner [9]. These include the practitioner's perception of the mental health problem being presented. There may be only limited overlap between the practitioner's assessment and the patient's understanding of the mental health problem for which treatment is being sought [8]. In selecting treatment for the problem, the practitioner may also consider the potential efficacy of different treatment options that might be offered and the acceptability and affordability of those treatments for this particular patient. Whether options are presented to the patient in a negotiating process will depend on the practitioner's views concerning the potential value of such discussion [7]. To each of these steps, practitioners inevitably bring their own values and attitudes as well as their health-care knowledge and understanding of the needs of the patient [10]. Link and Milcarek [6] found, for example, that practitioners demonstrated a preference for providing psychological therapy to young, highly educated and communicative patients, while those who are older or less educated are less likely to receive individual psychological therapy and more likely to be given less personalized care. Waitzkin [7] also reported differences in types of care provided to males and females, with women receiving more doctor time and being given more explanations. Earlier studies noted that the practitioner's perception of the patient's knowledge might affect the treatment recommended [8]. Various external factors can also affect the practitioner's choice of treatment, including the time allocated for this particular episode of care, pressures to maintain a heavy appointment schedule [11], and legal restrictions, for example whether the practitioner is legally permitted to prescribe certain medications.
Types of help provided to those presenting with mental health problems in the Australian health-care setting have not previously been explored. However, some of the factors explored above have been considered, for example, in an analysis of the structure of verbal interactions in general practice, and pressures reported by general practitioners during those interactions [11]. Overall, there has been little information collected on the types of help provided to those using mental health services and on factors associated with provision of these different types of care. This limitation has now been addressed in part by the completion of the National Survey of Mental Health and Wellbeing. This survey of a representative sample of Australians aged 18 and over living in the community was conducted in 1997 by the Australian Bureau of Statistics (ABS). The range of information collected covered sociodemographic, physical and psychological health measurements, levels of utilization of general and specialist medical services for treatment of mental health problems and the types of help provided as part of that treatment. Access to this data set has allowed us to explore the extent to which individuals' sociodemographic and psychological characteristics, as well as the types of practitioners from whom they received services, were associated with their obtaining particular types of help for mental health problems. We examined these associations using simultaneous multiple logistic regression analysis. This allowed us to assess the extent to which receiving particular types of help was related to each of the predictor variables, when controlling for other predictor variables, for example, mental health status of the recipient, or the type of practitioner providing that help.
Following Andersen and Newman's behavioural model [1], we considered three types of predictor variables: those relating to need for mental health services including diagnoses, symptoms of psychological distress and self-identified mental health problems; predisposing factors including age, sex, being separated or divorced; and enabling factors covering geographical location, education, income and whether the usual language spoken was English. Types of help included information about mental illness and its treatment; medication; psychological therapy; practical help to sort out problems concerning housing, money or ability to work; and help looking after oneself or one's home. We expected that types of help provided would largely be determined by need factors and the category of health practitioner seen. Other factors were expected to have a smaller role in determining the type of help provided. Should this not be the case, it would indicate inequalities in distribution of types of help for mental health problems.
Method
The National Survey
The National Survey was conducted throughout Australia in 1997. Response to this survey was voluntary and the survey sample drawn from residents of private dwellings [12]. Approximately 13 600 dwellings were approached with one person aged 18 years or over in each dwelling randomly chosen to participate in the survey. A total of 10 641 persons completed the survey interview giving a response rate of 78%.
Measures obtained
Sociodemographic details collected from each participant included age, sex, marital status, languages used, level of education, and employment status. Continuous measures of mental health and wellbeing included the General Health Questionnaire (GHQ) [13] and the Neuroticism scale of the short form of the Eysenck Personality Questionnaire – Revised (EPQ-R) [14]. The reliability and validity of these instruments have been previously confirmed [15]. Participants were also asked whether they had any of the following 12 chronic physical conditions: asthma, chronic bronchitis, anaemia, high blood pressure, heart trouble, arthritis, kidney disease, diabetes, cancer, stomach or duodenal ulcer, chronic gallbladder or liver trouble, and hernia or rupture.
Information on the mental health of each individual was obtained using those components of the Composite International Diagnostic Interview (CIDI) relating to affective, anxiety and substance-abuse disorders. While the reliability and validity of the CIDI has been assessed by a number of studies [16], other writers have expressed concern about the potential for this instrument to provide overestimates of the prevalence of mental disorder in the community [17]. The survey also included the Brief Disability Questionnaire, a standard questionnaire measuring general levels of disability in the 4 weeks before the interview, as well as a question on the number of days spent out of role over that period as a result of ill health. Respondents were asked to identify their most troubling mental health problem and the extent to which that particular problem had limited their activities.
Survey participants were also questioned about their use of health services and the categories of health professionals from whom they had obtained health care in the past year. They were then asked to specify whether they sought help for mental health problems during any of those visits. Those receiving such help were asked whether they had received any of 10 types of interventions. We grouped these interventions into five broad categories: (i) information about mental illness, its treatments and available services; (ii) medication (medicine or tablets); (iii) psychological therapy covering psychotherapy (discussion about causes that stem from the past), cognitive–behavioural therapy (learning to change thoughts, behaviours, emotions) and counselling (help to talk though problems or advice about how to cope with them); (iv) practical help (help to sort out housing or money problems, or to improve ability to work or use time in other ways); (v) and self-care help (help to improve ability to look after self or home).
Participants were classified as having a CIDI-diagnosed affective disorder, anxiety disorder or substance-abuse disorder if they were given one or more of the relevant ICD-10 codes. These broad categories of mental disorder were selected over more specific diagnoses since many of the latter have low-prevalence rates and high comorbidity with other diagnoses in the same category, thereby limiting their usefulness in analyses of community-based surveys. Self-identified mental disorders were similarly classified into categories of depression, anxiety and substance abuse.
Statistical methods
We undertook simultaneous multiple logistic regression analysis using predictor variables which included sociodemographic measures, psychological measures, self-identified mental health problems and CIDI-diagnosed mental disorders and type of health practitioner who provided help. Respondents were asked from which types of practitioners they had obtained mental health help. We grouped practitioners into four categories: general practitioners, psychiatrists, psychologists and other health professionals. The fourth category covered drug and alcohol counsellors, other counsellors, nurses, mental health teams, chemists and ambulances. We explored the effect of type of health-care provider by including in our regression analysis four predictor variables indicating whether or not mental health help had been obtained from general practitioners, psychiatrists, psychologists or other health professionals. All predictor variables are listed in Table 1. Each participant's survey information included a weighting factor provided by the ABS. Applying this factor gave survey estimates conforming to independent estimation of the Australian population during the time of the survey. Each survey record also included 30 replicate weights derived using the jackknife method of replication. Standard errors of prevalence estimates and confidence intervals for odds ratios were derived using the delete-1 jackknife method of replication [12]. Analysis was undertaken using the statistical package STATA Release 5 [18].
Descriptions of predictor variables and mean or median scores of those variables for respondents receiving no mental health help and those receiving any mental health help
Results
We first obtained mean or median measures of: sociodemographic variables; levels of psychological distress; self-identified mental health problems; CIDI diagnoses; and numbers of visits to different categories of health professional for two subgroups of the sample. These subgroups comprised respondents who obtained any mental health help in the past year (11.1% of the population), and the remainder who did not obtain such help. These results are given in Table 1.
For each of the 25 predictor variables considered, the mean or median scores for those who obtained any form of mental health help were statistically significantly different to the scores of those who did not obtain such help. Those receiving such help were more likely to be younger, female, separated or divorced than their non-help-seeking counterparts. They were less likely to have a usual language other than English or to live in a rural or remote area. As might be expected, they also had higher mean GHQ and EPQ-R Neuroticism scores, and greater prevalence levels of the common psychiatric disorders of depression, anxiety and substance abuse.
Within this subpopulation of mental health help recipients, 55.9% reported receiving medication, 55.1% received some form of psychological therapy, 25.1% were given information, 10.6% reported receiving practical help, and 6.6% obtained self-care help. For each of five dependent variables relating to type of help obtained, we then undertook simultaneous multiple logistic regressions to identify predictor variables associated with receiving that type of help. The results of these analyses are in Table 2.
Odds ratios for associations of receiving information, medication, psychological therapy, practical help and self-care help with sociodemographic and psychological measures, and type of health practitioners from whom help was obtained
We found four variables to be significantly associated with receiving information: being younger and seeing general practitioners, psychiatrists or psychologists. Four predictor variables were significantly associated with receiving medication: being older, having a higher EPQ-R Neuroticism score, and seeing a general practitioner or a psychiatrist. Five variables were significantly associated with receiving psychological therapy: being separated, having a lower EPQ-R Neuroticism score, and seeing a psychiatrist, psychologist, or other health professional. Predictor variables positively associated with receiving practical help were being divorced, having self-identified anxiety, and seeing a psychologists or other health professional. Reporting visiting a general practitioner for mental health reasons, however, was negatively associated with receiving practical help. Finally, only one variable was found to be significantly associated with receiving self-care help: obtaining mental health help from a psychiatrist.
Discussion
In this analysis, we sought to identify sociodemographic and health-related variables associated with the type of help obtained when receiving mental health services from health professionals in Australia. Five categories of help were considered: obtaining information, medication, psychological therapy, practical help and self-care help. We used simultaneous multiple logistic regression to explore associations between types of help received and predictor variables measuring sociodemographic factors, psychological distress and type of practitioner from whom services were obtained.
Predisposing and enabling factors
Three predisposing factors (age, being separated and being divorced) were found to be associated with significant differences in receiving particular types of help. After controlling for diagnosed or self-identified mental disorders, younger patients were found to be more likely to receive information. This implies that lower levels of information provided to older people are not simply the result of their having different morbidity patterns. Reasons for such age-related variation in the provision of information about mental illness and its treatments cannot be determined from these analyses.
Older respondents were also more likely to report receiving medication. Again, this age difference occurred when controlling for psychological distress, mental illness and type of practitioner seen. This result does not appear incompatible with the previous finding. It may be that those receiving information about their illness and its treatments may be offered a wider range of types of help including various forms of psychological therapy. The question again is: was medication the preferred care option of older patients or was this the most expedient option selected by prescribing health professionals as care for older people?
Separated or divorced people were also more likely to obtain particular types of mental health help. Separated respondents were more likely to report obtaining some form of psychological therapy, and divorced respondents more likely to obtain practical help. While those who are separated may find this time of relationship breakdown distressing [19], it is less clear why those who are divorced may be more likely to obtain practical help.
Need factors
Only two of the measures of psychological distress explored in the multiple logistic regression analyses were found to be associated with particular types of help received. The EPQ-R Neuroticism score was significantly higher for respondents who obtained medication, and significantly lower for those who reported receiving psychological therapy. This second result suggests that perhaps practitioners do not favour patients with longterm symptoms for psychological therapy.
Those with self-identified anxiety were more likely to receive practical help. Concerns about such practical matters as house and money problems may well result in an individual self-identifying as anxious to the health professional. These findings indicate the potential relationship between a person's stressful life events, coping strategies and sources of support, all of which may contribute to a decision to seek formal treatment [4, 19].
Factors relating to type of practitioner
We found that making a visit to a psychiatrist had the strongest association with receiving information, medication and self-care help and the second strongest association with receiving psychological therapy. This predictor variable, however, was the only practitionerrelated variable to have no association with receiving practical help.
Visiting a psychologist was associated with receiving information, psychological therapy and practical help. Visiting a general practitioner for mental health reasons was positively associated with receiving information and medication, but negatively associated with receiving practical help. Use of other health practitioners was significantly associated with receiving psychological therapy or practical help.
In general, these results are not surprising, although the limited role of general practitioners as information providers and prescribers is relevant for current initiatives in Australia looking to expand the role of these practitioners in treating mental health problems [20].
Limitations of this analysis
A number of the variables considered in this analysis are based solely on survey participants' responses. There was no means of confirming the accuracy of answers concerning the type of practitioner used or the type of help received. While respondents not using health services in a specified short period (for example, the previous 2 weeks) have been found to report erroneously that they did use such services, variation in levels of selfreporting and actual use of health services over a longer period such as that specified in this survey, has been found to be of much less concern [Marshall RP: unpublished data].
This survey provided only minimal information on health practitioners seen by respondents over the period. We had no information on the personal attributes or practice arrangements of health practitioners whose services were reported, for example, levels of expertise and billing practices of general practitioners who provided services. Nor did we have information on the health insurance status of respondents. The limited information that was available on types of practitioners seen allows us to make only very broad comments about the types of health provided by different categories of health practitioner.
We also acknowledge that our findings relate only to services provided for the common mental disorders of depression, anxiety and substance abuse. We have not explored the type of help provided those with other less common psychiatric conditions. Our analysis is further limited by the use of the CIDI, given the potential of this instrument to overestimate mental disorder [17].
Conclusions
One conclusion to be made from these analyses is that relatively few of the predictor variables we examined were significantly associated with the types of help people reported as receiving for their mental health problems. Of the sociodemographic factors examined, age group was the only one that predicted type of help received, indicating possible bias in practitioners' selection and provision of mental health help. These findings would suggest that older people who seek help for mental health problems are not being provided the range of treatments available to younger people who present with similar problems. Further research to determine whether those providing mental health services offer different types of help to older patients would be of value in clarifying this issue.
These findings apart, it could be concluded that any associations between type of help provided and other sociodemographic or health-related attributes are subsumed by the patterns of health practitioner utilization. While there may be inequalities in levels and patterns of utilization of mental health services in Australia [2], there are few factors that significantly affect the types of help received by those who have been able to obtain any mental health help.
Footnotes
Acknowledgements
The authors would like to thank Keith Dear and Scott Henderson for their help in preparing this paper.