Socio-economic status and geographies of psychiatric inpatient service use. Places, provision, power and wellbeing

The gravitational force of mental health services: distance decay effects in a rural Swiss service area

BACKGROUND

Previous research suggested a distance decay effect in health services systems, with people living closer to service facilities being more likely to use them.

METHOD

In this ecological cross sectional study, we conducted spatial and statistical analyses in a Swiss mental health services system being legally bound to provide primary mental health care to approximately 620,000 inhabitants. We examined a cohort of all patients who were over 18 years old and who were treated in the mental health services system between January and December 2011.

RESULTS

There were 5574 treatment cases during the 12-month period, 2161 inpatient cases and 3413 outpatient cases. Travel time by public transportation between patients' residence and the closest mental health service facility negatively predicted the utilization of outpatient services for all mental disorders, even after controlling for variability in ecological (e.g. socioeconomic) characteristics of the communities in the service provision area. For utilization of inpatient wards no geographical distance decay effect was observed, except for organic mental disorders.

CONCLUSIONS

Based on these findings, outpatient clinics should be most effectively located decentralized and in the largest communities to meet the needs of the population as close as possible to where people live and to avoid remote areas being insufficiently supplied with mental health care. For mental hospitals and inpatient services decentralized location seems to be less important.

Social inequalities in the utilization of outpatient psychotherapy: analyses of registry data from German statutory health insurance

Background

Most studies on health disparities deal with the occurrence of disease, but little is known about inequalities in the utilization of mental health services. This paper examines social inequalities in the utilization of outpatient psychotherapy within a health care system where there are low financial barriers to health care and a lack of specific health policies to address access to psychotherapeutic services.

Methods

Registry data of German statutory health insurance for the year 2013 were used (total population: N = 746,963; 10,711 women and men with psychotherapy). Logistic regression analyses were performed to estimate the effects of three socio-economic (SES) indicators on the utilization of psychotherapy.

Results

Utilization of psychotherapy by SES status did not correspond to the social structure of the insured population. Social disparities that disadvantaged less privileged women and men were found; this applied to education, income and occupational position. The most pronounced differences were found for education. In contrast, effects of income were rather small. These findings must be interpreted against the backdrop of the absence of financial barriers to outpatient psychotherapy in Germany.

Conclusions

A marked degree of psychotherapy under-utilization was found for lower SES groups. Psychotherapists should pay increased attention to clients with lower socio-economic position. Enhancing mental health literacy, as well as reducing the stigma of mental illness, is crucial for increasing the usage of psychotherapeutic services of those who need it most. Relevant health policy is needed to reduce the barriers to, and consequently increase psychotherapy utilization.

A conceptual framework for improving well-being in people with a diagnosis of psychosis

Background. Well-being is important for people with severe mental illness, such as psychosis. So far, no clear concept of well-being exists for this client group. A recent systematic review and narrative synthesis developed a static framework of well-being components. The present study aims to validate the static framework and to illuminate the processes by which well-being is experienced by people with psychosis. Methods. Semi-structured interviews were conducted with 23 service users with psychosis exploring their experience of well-being. Thematic analysis was used to analyse the data employing techniques taken from grounded theory to enhance the rigour of the analysis. Respondent validation was undertaken with 13 of the 23 participants. Results. Three superordinate categories of well-being were identified: current sense of self; transition to enhanced sense of self and enhanced sense of self. In the dynamic process of improving well-being the current sense of self undergoes a transition to an enhanced sense of self. The four factors influencing the transition are consistent with the static framework of well-being, hence validating the static framework. In addition, we identified three determinants of current sense of self and seven indicators of enhanced sense of self, which represent the achievement of improved well-being. Conclusions. This study provides an empirically defensible framework for understanding well-being in terms of determinants, influences and indicators. The influences are targets for interventions to improve well-being, and the indicators are outcome domains to assess the effectiveness of services in supporting well-being.

Prediction of community mental health service utilization by individual and ecological level socio-economic factors

Individuals with a more deprived socioeconomic status (SES) are more likely to have higher rates of psychiatric morbidity and use of psychiatric services. Such service use is also influenced by socioeconomic factors at the ecological level. The aim of this article is to investigate the influence of these variables on service utilization. All patients in contact with three Italian community psychiatric services (CPS) were included. Community and hospital contacts over 6 months were investigated. Socio-economic characteristics were described using a SES Index and two new Resources Accessibility Indexes. Low SES was found to be associated with more community service contacts. When other individual and ecological variables were controlled for, SES was negatively associated only with the number of home visits, which was about half the rate in deprived areas. An association between service utilization and the resources of the catchment area was also detected. The economic crisis in Europe is increasing inequality of access, so paying attention to SES characteristics at both the individual and the ecological levels is likely to become increasingly important in understanding patterns of psychiatric service utilization and planning care accordingly.

Area characteristics and admission rates of people with schizophrenia and affective disorders in a German rural catchment area

BACKGROUND

Studies in urban areas identified environmental risk factors for mental illness, but little research on this topic has been performed in rural areas.

METHODS

Hospital admission rates were computed for 174 rural municipalities in the catchment area of the state psychiatric hospital in Günzburg in years 2006 to 2009 and combined with structural and socio-economic data. Relationships of overall and diagnosis-specific admission rates with municipality characteristics were analysed by means of negative binomial regression models.

RESULTS

Admission rates of patients with a diagnosis of schizophrenia and affective disorder combined decrease with increasing population growth, population density, average income and green areas, while admission rates are positively correlated with commuter balance, income inequality, unemployment rates and traffic areas. Admission rates for schizophrenia are negatively related to population growth, average income and agricultural areas, but positively related to mobility index, income inequality and unemployment rate. Admission rates for affective disorders are negatively related to population growth, population density, average income and green areas, while higher admission rates are correlated with commuter balance, high income inequality, unemployment rate and traffic-related areas.

CONCLUSIONS

Effects of wealth, economic inequality, population density and structural area characteristics influence psychiatric admission rates also in rural areas.

How are caseload and service utilisation of psychiatric services influenced by distance? A geographical approach to the study of community-based mental health services

INTRODUCTION

The aim of this study was to assess how the caseload and the utilisation of community-based mental health services is influenced by distance and to socioeconomic characteristics.

METHODS

Spatial and statistical analyses were conducted with a sample of 12,347 patients, with ICD-10 psychiatric diagnosis, who had at least one contact with psychiatric services in Verona, Italy, between 2000 and 2006. Three types of mental health facility were considered: acute inpatient wards, outpatient clinics, and community mental health centres (CMHC). To measure distance and accessibility, the locations of static mental health facilities and patients' homes were geocoded. Data were organised in a spatial database, which included census blocks, catchment areas locations, road network graphs, patients' and facilities' locations. In order to calculate travel distances, patients' and facilities' locations were connected to the road network. Accessibility was modelled by using the Network Analyst Service Area Function and 13 Service Areas were created around all facility locations, by measuring distances along the street network. For the epidemiological analyses, patients and census block centroids were linked to the service areas by using spatial join techniques. Epidemiological and utilisation analyses were performed for each type of setting.

RESULTS

The facilities were not equally located in the catchment areas. Of particular significance, rural areas appear to be poorly served by mental health services. The distance decay effect exists, with different trends for the three types of facility. The caseload (number of patients using services) decreased with increasing distance; at a distance of 10 km, there was a decrease of 80, 60 and 85%, respectively, for CMHCs, inpatients wards and outpatients clinics. From the Poisson regression models, distance was significantly correlated (p value < 0.0001) with service use. Also univariate analyses showed a statistically significant association between distance and caseload for each type of setting (p value < 0.05), with a decrease in service use for each service area increase in distance (1.5% for acute inpatient wards, 2.0% for CMHC, and 2.1% outpatient clinics). By adding other predictors in the Poisson regression models, these percentages increased.

CONCLUSIONS

Further studies are needed to evaluate the influence of other factors, such as environmental variables, that may influence the use of mental health services.

What is the impact of socio-economic inequalities on the use of mental health services?

Amartya Sen, who received the Nobel Prize for Economics, has demonstrated that the incidence of deprivation, in terms ofcapability, can be surprisingly high even in the most developed countries of the world. The study of socio-economic inequalities, in relation to the utilisation of health services, is a priority for epidemiological research. Socio-economic status (SES) has no universal definition. Within the international research literature, SES has been related to social class, social position, occupational status, educational attainment, income, wealth and standard of living. Existing research studies have shown that people from a more deprived social background, with a lower SES, are more likely to have a higher psychiatric morbidity. Many studies show that SES influences psychiatric services utilization, however the real factors linking SES and mental health services utilisation remain unclear. In this editorial we discuss what is currently known about the relationship between SES and the use of mental health services. We also make an argument for why we believe there is still much to uncover in this field, to understand fully how individuals are influenced by their personal socio-economic status, or the neighbourhood in which they live, in terms of their use of mental health services. Further research in this area will help clarify what interventions are required to provide greater equality in access to mental health services.

Rural-urban comparison of contextual associations with self-reported mental health status

Ample evidence documents the association between individual-level risk factors and mental health status; relatively less is known about associations between features of the context in which individuals live and their mental health. The objective of this study is to assess differences in associations between contextual characteristics of both rural and urban settings and mental health status measured by the mental health component of the SF-12. Using state-representative data, we observed significant rural/urban differences in the association of mental health status with availability of health care resources but no significant associations in other contextual domains. Lack of overlap in contextual associations suggests that contextual influence operates differently in rural and urban settings and that interventions to improve mental health may not translate across settings.