Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys.

BACKGROUND: The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data. METHODS: Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes). CONCLUSIONS: The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.

The substitutability of outpatient primary care in rural community health centers for inpatient hospital care.

To determine whether outpatient medical care obtained at federally funded rural community health centers (CHCs) in Maine acts primarily as a substitute or as a complement to inpatient care, a study of 36 communities served by CHCs was conducted. The hospital use of CHC users (age- and sex-adjusted admissions, days, and length of stay) was compared with that of nonusers from the same communities in 1980. Statistically lower rates of hospital admissions and days were observed for all CHC patients and for selected groups based on their age, sex, and insurance status (specifically Medicaid or Medicare). Hospital use of CHC community populations was then compared with that of 24 comparison communities without access to CHCs, using multiple linear regression in a pre/post design. The model tested, which included rates of health center use, insurance penetration, poverty, and hospital availability, among other factors, did not detect any differences in hospital use between CHC community and comparison populations. These results and additional data presented on selected hospital diagnoses and insurance coverage suggest that treatment, and hospitalization incentives, of CHC providers may reduce hospitalization. Clinic providers lack the economic, professional, and institutional incentives to hospitalize. Additional study to determine the actual substitutability effect is indicated.