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

Socioeconomic status, psychotherapy duration, and return to work from disability due to common mental disorders

Objective Low socioeconomic status (SES) is a risk factor for work disability due to common mental disorders (CMDs), one possible reason being inequal use of services. Psychotherapy is an evidence-based treatment for CMDs. This study examines socioeconomic and sociodemographic differences in psychotherapy attendance and an association of psychotherapy duration with return to work (RTW).Methods The study subjects (N = 12,263) were all Finnish citizens granted a disability pension (DP) due to CMDs in 2010-2012. Numbers of psychotherapy sessions (maximum 200) were collected from the nine-year interval around the DP grant. Socioeconomic and sociodemographic differences in psychotherapy duration (dependent variable) among DP recipients were studied using multinomial logistic regression models, likewise, the association between psychotherapy duration and RTW (dependent variable) among temporary DP recipients was examined.Results Higher SES, female gender, and younger age were positively associated with attending longer psychotherapies and surpassing the early treatment termination level (>10 sessions). Attending 11-60 psychotherapy sessions was positively associated with full RTW and partial RTW, whereas longer psychotherapies were not. Early termination was positively associated with partial RTW only.Conclusion This study demonstrates varying tendencies among CMD patients from different backgrounds to attend long rehabilitative psychotherapies, which may create inequalities in RTW.

A qualitative interview study of patients' attitudes towards and intention to use digital interventions for depressive disorders on prescription

Background

Depressive disorders are an emerging public health topic. Due to their increasing prevalence, patients with depressive disorders suffer from the lack of therapeutic treatment. Digital health interventions may offer an opportunity to bridge waiting times, supplement, or even substitute in-person treatment. Among others, the Unified Theory of Acceptance and Use of Technology (UTAUT) explains that actual technology use is affected by users' behavioural intention. However, patients' perspectives on digital interventions are rarely discussed within the specific context of primary care provided by general practitioners (GP) and need further exploration.

Method

A qualitative study design with semi-structured interviews was used to explore DTx-acceptance of patients with mild or moderate depression (n = 17). The audio-recorded interviews were transcribed verbatim, coded, and thematically analysed by qualitative content analysis.

Results

Patients' performance expectancies reveal that DTx are not perceived as a substitute for face-to-face treatment. Effort expectancies include potential advantages and efforts concerning technical, motivational, and skill-based aspects. Moreover, we identified health status and experience with depressive disorders as other determinants and potential barriers to patients' DTx acceptance: Difficult stages of depression or long-time experience are perceived hurdles for DTx use. GPs' recommendations were just partly relevant for patients and varied according to patients' consultancy preferences. But still, GPs have a crucial role for access due to prescription. GPs' influence on patients' DTx acceptance varies between three situations: (1) pre-use for consultation, (2) pre-use for access and (3) during DTx-use. Further, GPs' guidance could be especially relevant for patients during DTx-use in routine care.

Discussion

The UTAUT-based exploration suggests that acceptance determinants should be considered independently and embedded in personal and situational aspects. DTx require a healthcare professional to prescribe or diagnose the disease, unlike other digital offerings. We identified prescription- and depression-related determinants, exceeding existing theoretical constructs. GPs' guidance can compensate for some barriers to DTx use e.g., by increasing commitment and motivational support to strengthen patients' acceptance.

Conclusion

We argue for a multidimensional integration of acceptance determinants for further development of health technology acceptance research. Future research should specify how DTx can be integrated into routine care to strengthen user acceptance.

The Evaluation of the GET.ON Nationwide Web-Only Treatment Service for Depression- and Stress-Related Symptoms: Naturalistic Trial

BACKGROUND

GET.ON (HelloBetter) treatment interventions have been shown to be efficacious in multiple randomized controlled trials.

OBJECTIVE

This study evaluated the effectiveness of 2 GET.ON interventions, GET.ON Mood Enhancer and GET.ON Stress, in a national digital mental health service implemented across Germany.

METHODS

Following an initial web-based questionnaire, participants were allocated to either intervention based on their baseline symptom severity and personal choice and received a semistandardized guided, feedback-on-demand guided, or self-guided version of the treatment. Uncontrolled routine care data from 851 participants were analyzed using a pretest-posttest design. Half of the participants (461/851, 54.2%) were allocated to the stress intervention (189/461, 41% semistandardized; 240/461, 52% feedback on demand; and 32/461, 6.9% self-guided), and almost all participants in the mood intervention (349/352, 99.2%) received semistandardized guidance.

RESULTS

Results on depression-related symptom severity indicated a reduction in reported symptoms, with a large effect size of d=-0.92 (95% CI -1.21 to -0.63). Results on perceived stress and insomnia indicated a reduction in symptom severity, with large effect sizes of d=1.02 (95% CI -1.46 to -0.58) and d=-0.75 (95% CI -1.10 to -0.40), respectively. A small percentage of participants experienced deterioration in depression-related symptoms (11/289, 3.8%), perceived stress (6/296, 2%), and insomnia (5/252, 2%). After completing treatment, 51.9% (150/289) of participants showed a clinically reliable change in depression-related symptoms, whereas 20.4% (59/289) achieved a close to symptom-free status. Similar improvements were observed in perceived stress and insomnia severity. Guidance moderated the effectiveness of and adherence to the interventions in reducing depressive symptom severity. Effect sizes on depression-related symptom severity were d=-1.20 (95% CI -1.45 to -0.93) for the semistandardized group, d=-0.36 (95% CI -0.68 to -0.04) for the feedback-on-demand group, and d=-0.83 (95% CI -1.03 to -0.63) for the self-guided group. Furthermore, 47.6% (405/851) of the participants completed all modules of the intervention. Participant satisfaction was high across all patient groups and both interventions; 89.3% (242/271) of participants would recommend it to a friend in need of similar help. Limitations include the assignment to treatments and guidance formats based on symptom severity. Furthermore, part of the differences in symptom change between groups must be assumed to be due to this baseline difference in the measures.

CONCLUSIONS

Future digital health implementation and routine care research should focus on monitoring symptom deterioration and other negative effects, as well as possible predictors of deterioration and the investigation of individual patient trajectories. In conclusion, this study supports the effectiveness of tailored digital mental health services in routine care for depression- and stress-related symptoms in Germany. The results highlight the importance of guidance in delivering internet-based cognitive behavioral therapy interventions and provide further evidence for its potential delivered as web-only solutions for increasing access to and use of psychological treatments.

Sociodemographic Factors as Predictors of the Duration of Long-term Psychotherapy: Evidence from a Finnish Nationwide Register Study

OBJECTIVE

The role of sociodemographic factors in determining psychotherapy duration has been largely unexplored despite their known association with treatment use. We examined the association between sociodemographic factors and rehabilitative psychotherapy treatment duration, as well as any changes in duration over time.

METHOD

We used three register-based nationally representative cohorts. Participants included employed Finnish individuals (n = 5572, 77% women, mean age = 37) who started psychotherapy treatment in 2011, 2013 or 2016 and were followed until 2019. We used negative binomial regression to examine the association between sociodemographic factors (age, gender, education, occupational status, income, geographical area of residence, and onset year of treatment) with treatment duration.

RESULTS

The mean treatment duration was 27 months (with a standard deviation of 12 months). Several sociodemographic factors were associated with treatment duration. Gender and education were found to have the largest impact on treatment duration, with females having a longer duration (IRR 1.08, 95% CI 1.04-1.11) and those with low education having a shorter duration (IRR 0.91, 95% CI 0.85-0.97), resulting in a difference of 2-3 months. Treatment duration also increased in later years, which suggests potentially increasing differences in treatment implementation. At largest, the combined effect of all factors corresponded to a 10-month difference in treatment duration.

CONCLUSIONS

The duration of long-term psychotherapy varied across the sociodemographic groups and increased in all studied groups in the 2010s.

Do values and political attitudes affect help-seeking? Exploring reported help-seeking for mental health problems in a general population sample using a milieu framework

AIMS

Help-seeking for mental health problems is facilitated and hindered by several factors at the individual, interpersonal and community level. The most frequently researched factors contributing to differences in help-seeking behaviour are based on classical socio-demographic variables, such as age, gender and education, but explanations for the observed differences are often absent or remain vague. The present study complements traditional approaches in help-seeking research by introducing a milieu approach, focusing on values and political attitudes as a possible explanation for differences in help-seeking for emotional mental health problems.

METHODS

A representative cross-sectional survey of N = 3,042 respondents in Germany was conducted through face-to-face interviews about past help-seeking for mental health problems, socio-demographic characteristics and values and political attitudes.

RESULTS

Multivariate logistic regression analyses indicated that belonging to a cosmopolitan intellectual milieu group was significantly associated with an increased likelihood of past help-seeking for mental health issues (psychotherapeutic/psychological help-seeking [OR = 2.09, 95% CI: 1.11-3.93, p < 0.05) and primary care (OR = 2.21, 95% CI: 1.15-4.24, p < 0.05]), whereas members of individualist and conservative milieu groups were less likely to report having sought help from a psychotherapist, but not from a general practitioner. Increased odds ratios were also found for a number of socio-demographic variables, such as being aged 26 years and over, a female gender and more than 12 years of formal education. Associations between socio-demographic variables remained significant, and the explained variance of the used models improved considerably when milieu variables were added.

CONCLUSIONS

We discuss how milieu-specific patterns were relevant for explaining differences in mental health service use in addition to socio-demographic factors. It seems promising to consider help-seeking from a milieu perspective to improve disparities in access to and the use of psychotherapy as well as to resource allocation.

Income inequalities beyond access to mental health care: a Dutch nationwide record-linkage cohort study of baseline disease severity, treatment intensity, and mental health outcomes

BACKGROUND

Existing literature shows low and unequal access to mental health treatment globally, resulting in policy efforts to promote access for vulnerable groups. Yet, there is little evidence about how inequalities develop once individuals start treatment. The greater use of mental health care among individuals with low income, such as in the Dutch system, might be driven by differences in need and might not necessarily lead to better treatment outcomes. In this study, we aimed to examine income inequalities in four stages of the mental health treatment pathway while adjusting for need.

METHODS

We constructed a nationwide retrospective cohort study, examining all patients aged older than 18 years with a first specialist mental health treatment record in the Netherlands between 2011 and 2016, excluding those who did not receive any treatment minutes. We linked patient-level data from treatment records to administrative data on income, demographics from municipal registries, and health insurance claims. We used multivariate models to estimate adjusted associations between household income quintile (standardised for household size) and outcomes characterising four stages of mental health treatment: severity at baseline assessment based on the Global Assessment of Functioning (GAF) score, treatment minutes received, functional improvement by the end of the initial record, and additional treatment in a subsequent record. Estimates were adjusted for patient need (97 categories of primary diagnosis and severity at baseline assessment measured by GAF) and demographic covariates.

FINDINGS

Our study population consisted of 951 530 adults with a first specialist mental health treatment record in the Netherlands between Jan 1, 2011, and Dec 31, 2016. Patients in our cohort were on average aged 45·0 years (range 19-107) and mostly female (529 859 [55·7%] women and 421 671 [44·3%] men; no ethnicity data were available). First, we found that patients with the lowest income had the greatest initial therapist-assessed disease severity (5·545 GAF points), which was 0·353 GAF points (95% CI 0·347-0·360) lower than those in the highest income quintile. Second, we found that the negative association between income and treatment minutes was reversed once we adjusted for diagnosis and severity at baseline, with patients with the lowest income receiving 1·8% fewer treatment minutes (95% CI 1·1-2·4) than those in the highest quintile. Third, those in the highest income quintile were 17·3 percentage points (95% CI 17·0-17·6) more likely to have functional improvements by the end of the initial record, compared with 25·8% of patients with an improvement in the lowest income quintile. Fourth, while 35·7% of patients in the lowest income quintile received additional treatment in a subsequent record, this was only 3·0 percentage points (95% CI 2·7-3·3) lower for those in the highest quintile. None of these patterns were explained by diagnosis, severity at baseline, or treatment minutes received.

INTERPRETATION

Disparities favourable to patients with a higher income persist through the different stages of mental health treatment. These differences highlight the limitations of solely focusing on improving access to care to reduce the mental health gap. Our findings call for a better understanding of the role of social environment and quality of care as complementary mechanisms explaining inequalities during mental health treatment.

FUNDING

Erasmus Initiative Smarter Choices for Better Health (Erasmus University Rotterdam), European Union's Horizon 2020, and Nederlandse Organisatie voor Wetenschappelijk Onderzoek (Dutch Research Council).

TRANSLATION

For the Dutch translation of the abstract see Supplementary Materials section.

Income gradient in psychotherapy use and psychotropic drug purchases: A longitudinal register study in Finnish employed population

OBJECTIVE

We examined the income gradient changes in the use of long-term rehabilitative psychotherapy and psychotropic drug purchases in men and women during a 9-year follow-up.

METHODS

We used register data from a random sample of the working-age population (18-64 years) with information on annual income, psychotherapy use and psychotropic drug purchases from 2011 to 2019 (N = 736 613, 49.7% women). Sex-stratified generalized estimating equations logistic regression models with predicted marginal probabilities were used to examine change in the treatment use rates over time for income quartiles.

RESULTS

Treatment rates increased during the follow-up, with men having lower rates than women. There were no significant differences in psychotherapy use rates between the income quartiles during the follow-up in men. A small income gradient in women (the wealthiest group with the highest use rate) remained stable throughout the follow-up. As for psychotropic drug purchases, the rates increased more among the poorest income quartile compared to the wealthiest quartile in both men and women. In the last year of the follow-up, the initial income gradient (wealthiest group having the highest psychotropic drug purchase rate) had become reversed, and the poorest group had the highest psychotropic drug purchase rate.

CONCLUSION

In psychotherapy use, no income gradient was found in men, while a stable income gradient was found in women. Psychotropic drug purchases have previously been more common in the wealthiest groups, but more recently among the poorest. The findings indicate that gender and income have distinct relationships with the treatment modality over time.

Socioeconomic status and access to psychotherapy

OBJECTIVE

Individuals with low socioeconomic status (SES) have significantly higher prevalence rates of mental disorders than those with higher SES, but are less likely to receive treatment. Studies from the United States show that individuals with higher SES are more likely to be offered a therapy place than those with low SES. In Germany, where the public health care system is without financial barriers, studies on access to treatment are lacking.

METHOD

The present study investigated whether the SES of persons seeking psychotherapeutic help in Germany influences psychotherapists' decision to provide access to treatment. For this purpose, 504 licensed outpatient psychological psychotherapists participated in an online study, in which they read a series of case vignettes and rated how likely they would be to offer treatment in each case. SES was operationalized by occupation and language use. Additionally, we investigated whether treatment offers were affected by the disorder and the gender of the help seeker, the therapists' socioeconomic background, and other characteristics in interaction with SES. Bonferroni-corrected multifactorial repeated measures analysis of variances (ANOVAs) and mixed ANOVAs were calculated.

RESULTS

Help seekers with low SES were 4.1% less likely to be offered treatment than those with moderate to high SES (F (1, 503) = 115.64; p = 0.000; η² =  0.187). The influence of SES on the probability of a therapy place offer varied significantly depending on the patient's disorder (p = 0.000): SES had a greater effect for bulimia than for depression and social anxiety disorder. Overall, the effect was small (η² = 0.026). No significant interaction between the gender of potential clients and SES was found (p = 0.062). The influence of SES on treatment accessibility varied depending on the therapeutic method for which the therapist was licensed and on the social status of the district in which the therapist's practice was located. The therapist's socioeconomic background (parental SES) did not interact with the potential client's SES.

CONCLUSION

Therapist biases contributing to unequal access to treatment for individuals with low SES and other characteristics can aggravate mental health care disparities. Even though the effects we found were relatively modest, awareness of the association between SES and offers of therapy places might help practitioners to reflect on their own selection practices.

Socioeconomic factors and use of psychotherapy in common mental disorders predisposing to disability pension

Background

Research in high-income countries has identified low socioeconomic status as a risk factor for disability pension (DP) due to common mental disorders (CMDs). Psychotherapy is an evidence-based treatment for the majority of CMDs along with medication and it is often targeted to prevent work disability. This study examines socioeconomic differences in the use of rehabilitative psychotherapy in Finland, where citizens have universal health coverage, but psychotherapy is partly dependent on personal finance.

Methods

The study subjects (N = 22,501) were all the Finnish citizens granted a DP due to CMD between 2010 and 2015 and a comparison group (N = 57,732) matched based on age, gender, and hospital district. Socioeconomic differences in psychotherapy use were studied using logistic regression models. Socioeconomic status was defined by education, income, and occupation. Age, gender, and family status were also examined.

Results

A lower level of education, lower occupational status (blue-collar worker), male gender, and older age, were associated with less frequent psychotherapy use, in both groups. Education was the strongest component of socioeconomic status associated with psychotherapy use, but the role of income was not straightforward. Unemployment when approaching DP, but not otherwise, was a risk factor for not receiving rehabilitative psychotherapy. Socioeconomic disparities were not any smaller among CMD patients approaching DP than in the comparison group.

Conclusion

This study demonstrates the disparity in the provision of psychotherapy for CMD patients, even on the verge of DP with an acute need for services. This disparity is partly related to a complex interplay of socioeconomic factors and the service system characteristics. Factors predisposing to unequal access to mental health services are presumably diverse and should be studied further.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08389-1.

Investigating unrecognized needs and structural barriers to treatment of depressive symptoms: A nationwide cross-sectional study in Portugal

This study assesses factors associated with perception of need and affordability concerns regarding mental health services (MHS), among 978 persons with meaningful depressive symptoms (Patient Health Questionnaire≥10). We used data from the 6th Portuguese National Health Interview Survey and used logistic regressions with gender, age, severity of symptoms, education, and income as explanatory variables. Health insurance was added as mediation variable. Unrecognized need (59.3% of the sample) was more likely amongst men, those over 65, high-educated, and those with moderate symptoms, compared to women, aged 18-34, low-educated, and those with severe symptoms. Among those reporting they needed MHS, 44.6% were not able to pay for them. Affordability concerns were more likely amongst men, those under 50, severely depressed, high-educated, and less likely amongst those within the highest income quintile. Adjusting for health insurance did not change the results in a meaningful way. Unrecognized need and affordability concerns are common among depressed persons in Portugal but seem unevenly distributed across social groups. Investing in the capacity of primary healthcare services to treat depression may be crucial to promote perception of need and reduce structural barriers.

Psychiatric Comorbidity in Prurigo Nodularis and the Impact of Socioeconomic Status

OBJECTIVE

We sought to investigate the relationship between psychiatric comorbidity, socioeconomic status (SES), and mental health utilization among patients with prurigo nodularis (PN).

METHODS

We conducted a retrospective cohort study of patients with PN from 2007 to 2019. SES was approximated using zip codes; per capita income data was compared to the Livable Income Threshold.

RESULTS

288 patients were included. Patients were predominantly female (57%) and significantly more likely to have a psychiatric disorder than men (p=0.001). 44.1 percent of patients had at least one psychiatric comorbidity, with mood (74.8%) and anxiety (63.0%) disorders being most common. Patients with PN in lower SES groups had a higher incidence of psychiatric disorder (p=0.566) and utilization of mental health services (p=0.617). 40.9 percent of patients with a diagnosed psychiatric disorder had no record of seeing a psychiatrist or psychologist.

LIMITATIONS

Patient records were retrospectively reviewed for encounters with a psychiatrist or psychologist, but did not account for other forms of mental health services. Per capita income used to determine SES may not be an accurate representation of an individual's income, nor did it account for the number of people within a household.

CONCLUSION

Psychiatric comorbidity was common among patients with PN and many went without receiving mental health services. Further studies with larger sample sizes are needed to better understand the impact of SES on these factors.

Trauma assessment in outpatient psychotherapy and associations with psychotherapist's gender, own traumatic events, length of work experience, and theoretical orientation

BACKGROUND

Traumatic events are strongly associated with mental health problems. At present, traumatic events and trauma-specific needs are commonly underdetected in therapeutic settings. Many mental health professionals lack key competencies for trauma inquiry and treatment.

OBJECTIVE

In this study, we aimed to investigate the everyday practices of dealing with traumatic events in outpatient psychotherapy in Germany as well as the influence of the therapist's gender, own traumatic events, length of professional experience, and theoretical orientation.

METHOD

A total of 148 outpatient psychotherapists completed a purpose-designed online questionnaire. Therapists rated barriers and attitudes towards trauma assessment, possible requirements for enquiring about trauma, and practical aspects of trauma assessment.

RESULTS

Barriers reported in previous studies, e.g. fear of offending the patient or exacerbating their psychological state, could not be confirmed in our sample. Overall, participating therapists felt confident in engaging with traumatic events and considered enquiring about trauma important in all patients. Group differences were found for therapist's gender, own traumatic events, length of work experience, and theoretical orientation.

CONCLUSIONS

Our results suggest that trauma training lowers barriers and raises therapists' self-confidence in dealing with patients´ traumatic experiences. Therapists' characteristics effecting trauma assessment should be considered during training. Due to the increasing demand for psychotherapy, especially considering people with severe mental illness affected by traumatic events, trauma training should be obligatory for all mental health professionals.

Gender gap in health service utilisation and outcomes of depression: A cross-country longitudinal analysis of European middle-aged and older adults

Research has shown that health service utilisation for depression (HSUD) is less common among men than women. However, most evidence is cross-sectional, and there is limited information about gendered outcomes of depression. This cross-country study assesses gender differences in HSUD and in the persistence of depression by using cross-sectional and longitudinal data. We used data from the Survey of Health, Ageing and Retirement in Europe (SHARE), from 5428 participants between 50 and 80 from nine European countries, fulfilling criteria for depression in Wave 5 (assessed by the EURO-D depression scale). We modelled non-HSUD among all those depressed in Wave 5 ("cross-sectional data") and those not depressed in Wave 4 ("longitudinal data"), and the persistence of depression in Wave 6, as a function of gender. We used logistic regressions adjusted for age, marital status, country, education, financial strain, and severity of depression. Non-HSUD was more likely among depressed men than women in both cross-sectional (82.4% vs 73.2%, OR = 1.54, 99%CI = 1.54-1.55) and longitudinal analyses (94.4% vs 88.3%, OR = 2.27, 99%CI = 2.25-2.29). Gender differences were greater among low-educated participants and those with less pronounced financial strain. Among those with HSUD, men were more likely to remain depressed (62.3%, OR = 2.26, 99%CI = 2.22-2.30). Among those without HSUD, depression was more likely to persist among women (45.4%, OR = 0.79, 99%CI = 0.78-0.79). Results suggest that cross-sectional analyses underestimate men's disadvantage in HSUD. Interventions are needed to improve the demand for care and treatment adequacy among men, increasing their perception of need and their mental health literacy.

Protocol for a sequential, multiple assignment, randomised trial to test the effectiveness of message-based psychotherapy for depression compared with telepsychotherapy

INTRODUCTION

Digital mental health tools have become popular alternatives to traditional psychotherapy. One emerging form of digital mental health is message-based care, the use of text messages or asynchronous voice or video messaging to provide psychotherapy. There has been no research into whether this is an effective method of psychotherapy as a stand-alone treatment or in combination with traditional psychotherapy.

METHODS AND ANALYSIS

This is a sequential, multiple assignment randomised trial to compare message-based care, videoconference-psychotherapy and a combination of the two treatments in 1000 depressed adults. Participants will be recruited through Talkspace, a digital mental health company, and randomised to receive 6 weeks of either message-based care only or videoconference-psychotherapy only. At 6 weeks, participants will be evaluated for their response to treatment. Those with a 50% or more response to treatment will continue with their assigned condition. Those who do not respond will be randomised to either monthly videoconference-psychotherapy or weekly videoconference-psychotherapy plus message-based care. Primary outcomes will be depression and social functioning. We will also explore moderators of treatment outcome.

ETHICS AND DISSEMINATION

The study received ethics approval from the University of Washington Institutional Review Board. Results of this study will be presented in peer-reviewed journals and at professional conferences.

TRIAL REGISTRATION NUMBER

NCT04513080; Pre-results.

[Completely Different or Quite Similar? The Sociodemographic Structure of the AOK Lower Saxony in Comparison to the General and Working Population in Lower Saxony and the Federal Republic of Germany]

ZIEL DER STUDIE

Routinedaten von Krankenkassen sind als Datenquelle mittlerweile gut etabliert. Hinsichtlich der Verallgemeinerbarkeit der Ergebnisse bei Analysen mit Daten einer Krankenkasse treten Fragen der Repräsentativität der Versichertenpopulation auf, insbesondere da nicht alle Studien auf soziodemografische Merkmale adjustieren. Diese Arbeit untersucht mittels deskriptiver Analyse, ob und inwieweit sich die Sozialstruktur der Versichertenpopulation der AOK Niedersachsen von der Sozialstruktur der Allgemeinbevölkerung und der sozialversicherungspflichtig Beschäftigten in Niedersachsen (NDS) und in der Bundesrepublik (BRD) unterscheiden.

METHODIK

Die Datengrundlage bilden pseudonymisierte Daten der AOK NDS, die Beschäftigtenstatistik der Bundesagentur für Arbeit und der Bevölkerungsstand in NDS und der BRD. Die Versichertenpopulation wird an zwei Stichtagen 31.12.2012 und 31.12.2017 hinsichtlich der Geschlechter-und Altersstruktur mit der Bevölkerung in NDS und der BRD verglichen. Anschließend werden die Daten der sozialversicherungspflichtig Beschäftigten in der AOK NDS und aus der Beschäftigtenstatistik der Bundesagentur für Arbeit gegenübergestellt, um Ausbildungsabschlüsse, Komplexität der ausgeübten Tätigkeit und elf Berufsbereiche zu vergleichen.

ERGEBNISSE

Die Geschlechterstruktur unterscheidet sich nicht zwischen den drei Vergleichspopulationen. Verglichen mit der Bevölkerung in NDS und der BRD ist der Anteil der unter 30-Jährigen in der AOK NDS überdurchschnittlich, der Anteil der Personen zwischen 50 und 76 Jahren etwas unterdurchschnittlich. Sozialversicherungspflichtig Beschäftigte mit Hochschulabschluss und in Tätigkeiten mit höherer Komplexität sind in der AOK NDS unterrepräsentiert. Die Verteilung der sozialversicherungspflichtig Beschäftigten auf elf Berufsbereiche unterscheidet sich ebenfalls.

SCHLUSSFOLGERUNG

Die Studie zeigt, dass soziodemographische und sozio-ökonomische Merkmale in Studien mit Krankenkassendaten wann immer möglich berücksichtigt werden sollten. In Zukunft wird das Informationssystem Versorgungsdaten krankenkassenübergreifende Analysen mit Sekundärdaten ermöglichen. Fragestellungen der gesundheitlichen Ungleichheit können damit jedoch aufgrund des Fehlens von sozio-ökonomischen Merkmalen nicht beantwortet werden. Auch die Identifikation von vulnerablen Gruppen, die gezielt geeigneten Maßnahmen zugeführt werden könnten, ist ohne Berücksichtigung von sozio-ökonomischen Merkmalen erschwert.

AIM OF THE WORK

Routine data from statutory health insurance funds are now a well-established source of data for scientific research. With regard to the generalizability of findings based on data from one health insurance fund, questions arise regarding the representativeness of the insured population, especially since not all studies adjust for socio-demographic characteristics. Our study examines whether and to what extent socio-demographic and occupational characteristics of the population insured with the AOK Lower Saxony differ from the total and working population of Lower Saxony and the Federal Republic of Germany.

METHODS

The analyses are based on pseudonymised data from the AOK, the employment statistics of the Federal Employment Agency (FEA) and population statistics. The insured population was compared with the population of Lower Saxony and Germany at two cut-off dates (31.12.2012 and 31.12.2017) with respect to the distributions of age and gender. Subsequently, data of employed insured persons were compared with FEA-data in order to compare educational level, complexity of the work and occupational areas.

RESULTS

The gender structure did not differ between the three populations. The proportion of insured women and men below 30 years of age was above the corresponding figures of Lower Saxony and Germany. Employed individuals holding a university degree or jobs with higher complexity were under-represented in the AOK. The distribution across eleven occupational areas in the AOK also differed from the reference populations.

CONCLUSIONS

The study shows that socio-demographic and socio-economic characteristics should be considered whenever possible in studies using statutory health insurance data. In future, the new database "Information System Health Care Data" will enable analyses across all statutory health insurance providers. However, research questions of health inequalities cannot be answered with this approach due to the lack of socio-economic characteristics in these data. Identifying vulnerable groups that could be targeted for appropriate interventions is also difficult without taking socio-economic characteristics into account.

Utilisation of outpatient medical services in Germany - Results from GEDA 2019/2020-EHIS

Outpatient health care provision plays an important role in the identification and treatment of health problems. Data are needed on the utilisation of health care services and their determinants to enable health policy decision-making and needs-based care provision. The analyses set out in this article are based on current data on the utilisation of outpatient health care services. The data stem from the German Health Update (GEDA 2019/2020-EHIS), a nationwide cross-sectional survey of the resident population in Germany that is undertaken as part of the health monitoring conducted at the Robert Koch Institute. Around 80% of the population aged 18 or over were treated at least once within twelve months by a general practitioner, 60% by a specialist, and 10% received psychiatric or psychotherapeutic treatment. Less than half of those eligible had had a stool test during the past two years, and just over half had had a colonoscopy in the past ten years. Around 80% of women and 70% of men had had their blood pressure checked within the last year, and 60% had had their blood cholesterol or blood sugar levels monitored. Over 50% reported that they had taken medically prescribed drugs in the past two weeks. In general, most of the indicators under study suggest that utilisation increases with age and that utilisation is higher among women than men, with the exception of psychiatric and psychotherapeutic services, among others.

The asymmetries of the biopsychosocial model of depression in lay discourses - Topic modelling online depression forums

BACKGROUND

One of the most comprehensive approaches to depression is the biopsychosocial model. From this wider perspective, social sciences have criticized the reductionist biomedical discourse, which has been dominating expert discourses for a long time. As these discourses determine the horizon of attributions and interventions, their lay interpretation plays a central role in the coping with depression.

METHODS

In order to map these patterns, online depression forums are analyzed with natural language processing methods, where computational tools are complemented with a qualitative approach. Latent Dirichlet Allocation topic model of depression-related posts from the most popular English-speaking online health discussion forums (N = ~70 000) reveals the monolog (attributions and self-disclosures) and interactive (consultations and quasi-therapeutic interactions) patterns.

RESULTS

Following the evaluation of various models 18 topics were differentiated: attributions referring to health, family, partnership and work issues; self-disclosures referring to contemplations, introducing the experience of suffering and well-being, along with diaries of everyday activities and hardships; consultations about psychotherapies, classifications, drugs and the experience; and quasi-therapeutic interactions relying on unconditional positive regards, recovery helpers experience or spirituality. These topics were evaluated from the perspective of the biopsychosocial model: the weight of each dimension was measured along with the discursive function.

CONCLUSIONS

Biomedical discourse is underrepresented in lay discussions, while psychological discourse plays an overall dominant role. Even if actors are initially aware of the social mechanisms contributing to depression, they neglect these factors when it comes to considering the countermeasures.

[Sociodemographic and Disorder-Specific Determinants for Professional Help-seeking due to Depression in a Structurally Weak Region - The Important Role of Age]

OBJECTIVE

Study of sociodemographic and disorder-specific determinants of professional help-seeking in lifetime depression.

METHODS

In the population-based SHIP-Trend-1 study (2016-2019), we assessed N = 490 adults with lifetime depression and their help-seeking behaviour. Gender, socioeconomic status and disorder-specific variables were implemented in age-stratified logistic regression models.

RESULTS

Men and older adults at the time of the survey sought less help than women and younger people. In the younger and middle age group severity level was associated with professional help-seeking, in the older age group professional help-seeking was more prevalent in case of physical causes for the depression.

CONCLUSION

We found age-specific differences in the determinants for professional help-seeking. Latent variables like age-specific experiences, values, and life styles may explain those differences.

Sex differences in pharmacological treatment of major depressive disorder: results from the AMSP pharmacovigilance program from 2001 to 2017

Data on drug prescription for outpatients with major depressive disorder (MDD) suggest women are more likely to be treated with psychotropic drugs, while data on sex differences regarding pharmacological treatment of psychiatric inpatients are currently not available. Drug utilization data from the program "Drug Safety in Psychiatry" (German: Arzneimittelsicherheit in der Psychiatrie, AMSP) of 44,418 psychiatric inpatients with MDD were analyzed for sex differences between 2001 and 2017. Sex differences were analyzed using relative risks (RR) and 95% confidence intervals (95% CI). Time trends were analyzed by comparing the first (2001-2003) with the last time period (2015-2017). In general, men and women were equally likely to use psychotropic drugs. Monotherapy was more common in men. Women were more likely to utilize ≥ 4 psychotropic drugs. Antidepressant drugs (ADDs) were the most prescribed drug class. Men had a higher utilization of noradrenergic and specific serotonergic antidepressants (RR 1.15; 95% CI 1.12-1.19), especially mirtazapine (RR 1.16; 95% CI 1.12-1.19), but also of other ADDs such as bupropion (RR 1.50; 95% CI 1.35-1.68). Males had a slightly higher utilization of second-generation antipsychotic drugs (RR 1.06; 95% CI 1.03-1.09) and were less often treated with low-potency first-generation antipsychotic drugs (RR 0.86; 95% CI 0.83-0.90). Tranquilizing (e.g., benzodiazepines; RR 0.89; 95% CI 0.86-0.92) and hypnotic drugs (e.g., Z-drugs; RR 0.85; 95% CI 0.81-0.89) were less utilized in the treatment of male patients. Not all sex differences were stable over time. More sex differences were detectable in 2015-2017 than in 2001-2003. Findings suggest that certain psychotropic drugs are preferred in the treatment of men vs. women, however, sex differences found in this study are not as large as in ambulatory settings. To make evidence-based sex-specific recommendations in the treatment of MDD, differences in drug response and tolerability need to be further researched.

Interaktive Gesundheitskompetenz, soziodemografische Faktoren und der Zeitraum bis zur Inanspruchnahme psychotherapeutischer oder medikamentöser Behandlung – gibt es Hinweise auf soziale Ungleichheiten in der Therapie der Sozialen Angststörung?

Ziel Ziel ist die Untersuchung des Zusammenhangs zwischen soziodemografischen Merkmalen sowie der interaktiven Gesundheitskompetenz und dem Zeitraum zwischen der Behandlungsentscheidung und der Inanspruchnahme einer Therapie der Sozialen Angststörung.

Methodik Hierzu wurde eine Online-Befragung von N = 311 Personen mit Sozialer Angststörung durchgeführt (Responserate 54,1 %). Neben deskriptiven statistischen Verfahren wurde eine logistische Regressionsanalyse durchgeführt.

Ergebnisse Die Befragten sind durchschnittlich 46 Jahre alt (20–81), 59 % sind Frauen. Höheres Alter (OR 2,579), nicht in Partnerschaft lebend (OR 1,963), Angst vor persönlichen Kontakten (OR 5,716) und geringe (OR 3,585) bzw. mäßige (OR 3,144) interaktive Gesundheitskompetenz sind signifikant mit der Wartezeit auf eine Behandlung assoziiert.

Schlussfolgerung Die Ergebnisse können als Hinweise auf soziale Ungleichheiten in Bezug auf die Inanspruchnahme einer Therapie bei Personen mit sozialer Angststörung gedeutet werden.

Are there social gradients in the occurrence of lung cancer and in the survival of lung cancer patients? Findings from an observational study using German claims data of Lower Saxony

OBJECTIVES

Only a few studies on health inequalities in terms of lung cancer are available. We examined whether social inequalities are present for the occurrence of lung cancer. Confining the analyses to patients, it was also examined whether survival over the observation period and over a standardised period of 18 months differed by occupational position and income.

METHODS

Our findings are based on claims data from a German statutory health insurance covering 2005-2016. The database comprised N=3 163 211 women (50.7%) and men (49.3%) aged 18 years and older. Diagnoses (International Statistical Classification of Diseases and Related Health Problems 10th Revision: C34.0 to C34.9) were hospital-based, and income and occupational position were used as indicators of socioeconomic position. Analyses on social gradients were performed for employed and retired insured, but only for employed insured information on occupation and on income were available, for retired women and men only income was available. Analyses were performed by means of proportional hazard regression.

RESULTS

In employed women, social gradients for the occurrence emerged for occupational position, but not for income. In men, social differences were found for both indicators. For retired insured, income gradients were found in men. Looking at overall survival, neither in women nor in men social gradients emerged.

CONCLUSIONS

The reported social inequalities in the occurrence of lung cancer are pointing towards social differences in smoking behaviour, exposition to hazardous occupation-related substances and differences in preventive strategies. The absence of social inequalities in survival after lung cancer suggests equality in medical treatment of the disease.

Patient Input in Regional Healthcare Planning-A Meaningful Contribution

Background: There are well-known methodological and analytical challenges in planning regional healthcare services (HCS). Increasingly, the need for data-derived planning, including user-perspectives, is discussed. This study aims to better understand the possible contribution of citizen experience in the assessment of regional HCS needs in two regions of Germany. Methods: We conducted a written survey in two regions of differing size-a community (3653 inhabitants) and a county (165,211 inhabitants). Multinomial logistic regression was used to assess the impact of sociodemographic and regional factors on the assessment of HCS provided by general practitioners (GPs) and specialists. Results: Except for age and financial resources available for one's own health, populations did not differ significantly between the regions. However, citizens' perception of HCS (measured by satisfaction with 1 = very good to 5 = very poor) differed clearly between different services (e.g., specialists: 3.8-4.3 and pharmacies: 1.7-2.5) as well as between regions (GPs: 1.7-3.1; therapists: 2.9-4). In the multivariate model, region (next to income and age) was a consistent predictor of the perception of GP- and specialist-provided care. Discussion: Citizens' perceptions of HCS correspond to regional provider density (the greater the density, the better the perception) and add insights into citizens' needs. Therefore, they can provide valuable information on regional HCS strengths and weaknesses and are a valid resource to support decision makers in shaping regional care structures.

[Socioeconomic status and health insurance expenditures for children and adolescents with conduct disorder : An analysis of statutory health insurance data]

BACKGROUND

For various psychiatric and somatic disorders, there is evidence of an association between patients' socioeconomic status (SES), healthcare utilisation, and the resulting costs. In the field of child and adolescent psychiatric disorders, studies on this topic are lacking.

OBJECTIVES

To exploratively analyse the association of healthcare expenditures for children and adolescents with conduct disorder (including oppositional-defiant disorder) - one of the most prevalent child and adolescent psychiatric disorders - and SES.

MATERIALS AND METHODS

The analysis is based on routine data from the German statutory health insurance company AOK Nordost for the calendar year 2011, covering 6461 children and adolescents (age 5-18 years) with an ICD-10 diagnosis of conduct disorder. The insureds' SES was estimated indirectly, based on the social structure of the postcode area, using the German Index of Multiple Deprivation (Mecklenburg-Vorpommern, Brandenburg), and the Berliner Sozialindex I (Berlin), respectively. From the two indices, quintiles were derived. Based on these quintiles, average costs per case for the following cost types were analysed: inpatient healthcare, outpatient healthcare (general practitioners, paediatricians, child and adolescent psychiatrists, child and adolescent psychotherapists), and prescribed medication.

RESULTS

There was no significant functional association between SES and healthcare costs for any of the analysed cost types.

CONCLUSIONS

In contrast to findings in adults, this study on children and adolescents with conduct disorders did not reveal an association between SES and healthcare costs. Within this group of patients, social inequality does not seem to have a significant influence on healthcare utilisation in Germany.

Public attitudes towards healthcare policies promoting tobacco cessation in Germany: results from the representative German study on tobacco use (DEBRA study)

OBJECTIVE

The aim of this study was to assess public acceptance of four possible healthcare policies supporting tobacco dependence treatment in line with the Framework Convention for Tobacco Control, Article 14 recommendations in Germany.

DESIGN

Cross-sectional household survey.

SETTING

Data were drawn from the German population and collected through computer-assisted, face-to-face interviews.

PARTICIPANTS

Representative random sample of 2087 people (>14 years) from the German population.

OUTCOME MEASURES

Public acceptance was measured regarding (1) treatment cost reimbursement, (2) standard training for health professionals on offering cessation treatment, and making cessation treatment a standard part of care for smokers with (3) physical or (4) mental disorders. Association characteristics with smoking status and socio-economic status (SES) were assessed.

RESULTS

Support for all policies was high (50%-68%), even among smokers (48%-66%). Ex-smokers and never-smokers were more likely to support standard training on cessation for health professionals than current smokers (OR 1.43, 95% CI 1.07 to 1.92; OR 1.43; 95% CI 1.14 to 1.79, respectively). Ex-smokers were also more likely than current smokers to support cessation treatment for smokers with mental disorders (OR 1.39, 95% CI 1.11 to 1.73). Men were less likely than women to support cessation treatment for smokers with physical diseases (OR 0.74, 95% CI 0.60 to 0.91) and free provision of treatment (OR 0.80, 95% CI 0.66 to 0.97). Offering cessation treatment to smokers with physical disorders was generally more accepted than to those with mental health issues.

CONCLUSIONS

The majority of the German population supports healthcare policies to improve the availability and affordability of tobacco dependence treatment. Non-smokers were more supportive than current smokers of two of the four policies, but odds of support were only about 40% higher. SES characteristics were not consistently associated with public acceptance.

TRIAL REGISTRATION NUMBER

DRKS00011322.

Are perceived barriers to accessing mental healthcare associated with socioeconomic position among individuals with symptoms of depression? Questionnaire-results from the Lolland-Falster Health Study, a rural Danish population study

OBJECTIVE

To evaluate if perceived barriers to accessing mental healthcare (MHC) among individuals with symptoms of depression are associated with their socio-economic position (SEP).

DESIGN

Cross-sectional questionnaire-based population survey from the Lolland-Falster Health Study (LOFUS) 2016-17 of 5076 participants.

PARTICIPANTS

The study included 372 individuals, with positive scores for depression according to the Major Depression Inventory (MDI), participating in LOFUS .

INTERVENTIONS

A set of five questions on perceived barriers to accessing professional care for mental health problem was posed to individuals with symptoms of depression (MDI score >20).

OUTCOMES

The association between SEP (as measured by educational attainment, employment status and financial strain) and five different types of barriers to accessing MHC were analysed in separate multivariable logistic regression models adjusted for gender and age.

RESULTS

A total of 314 out of 372 (84%) completed the survey questions and reported experiencing barriers to MHC access. Worry about expenses related to seeking or continuing MHC was a considerable barrier for 30% of the individuals responding and, as such, the greatest problem among the five types of barriers. 22% perceived Stigma as a barrier to accessing MHC, but there was no association between perceived Stigma and SEP. Transportation was not only the barrier of least concern for individuals in general but also the issue with the greatest and most consistent socio-economic disparity (OR 2.99, 95% CI 1.19 to 7.52) for the lowest vs highest educational groups and, likewise, concerning Expenses (OR 2.77, 95% CI 1.34 to 5.76) for the same groups.

CONCLUSION

Issues associated with Expenses and Transport were more frequently perceived as barriers to accessing MHC for people in low SEP compared with people in high SEP. Stigma showed no association with SEP.Informed written consent was obtained. Region Zealand's Ethical Committee on Health Research (SJ-421) and the Danish Data Protection Agency (REG-24-2015) approved the study.

Health inequalities in terms of myocardial infarction and all-cause mortality: a study with German claims data covering 2006 to 2015

OBJECTIVES

International comparisons are suggesting that mortality inequalities may have changed in the last years, although not always into the same direction. Only a few studies examined myocardial infarction (MI). In our study, long-term developments of MI and all-cause mortality were considered by analysing social gradients by income.

METHODS

German claims data covering 2006 to 2015 (N = 2,474,448) were used with myocardial infarction and all-cause mortality as outcomes. Socio-economic position was depicted by individual income. Health inequalities were measured by hazard ratios between and within income groups for 10 consecutive calendar years.

RESULTS

In men, income gradients of MI and all-cause mortality were decreasing. In women, no income gradients emerged for MI, and they disappeared in mortality. In men, hazard ratios of MI and mortality decreased in the intermediate and in the lowest income thirds, thus leading to a reduction of MI-related health inequalities.

CONCLUSIONS

Income inequalities in terms of myocardial infarction and of mortality have narrowed in men, and those in the lowest income third were profiting most. No such changes were observed in women.

Widening inequalities in multimorbidity? Time trends among the working population between 2005 and 2015 based on German health insurance data

BACKGROUND

Previous research has produced evidence for social inequalities in multimorbidity, but little is known on how these disparities change over time. Our study investigates the development of social inequalities in multimorbidity among the middle-aged and older working population. Special attention is paid to whether differing time trends between socio-economic status (SES) groups have taken place, increasing or decreasing inequalities in multimorbidity.

METHODS

The analyses are based on claims data of a German statutory health insurance company covering an observation period from 2005 to 2015. Multimorbidity prevalence risks are estimated using logistic generalized estimation equations (GEE) models. Predicted probabilities of multimorbidity prevalence are used to assess time trends in absolute social inequalities in terms of educational level, income, and occupational group.

RESULTS

The prevalence risks of multimorbidity rose among all SES groups and social gradients persist throughout the observation period, indicating significantly higher multimorbidity prevalence risks for individuals with lower SES. Widening absolute inequalities are found among men in terms of educational level and among women in terms of occupational groups.

CONCLUSIONS

The increases in multimorbidity prevalence among the working population are accompanied by widening social inequalities, pointing towards a growing disadvantage for men and women in lower SES groups. The rising burden and the increasing inequalities among the working population stress the importance of multimorbidity as a major public health concern.

Widening inequalities in multimorbidity? Time trends among the working population between 2005 and 2015 based on German health insurance data

Background

Previous research has produced evidence for social inequalities in multimorbidity, but little is known on how these disparities change over time. Our study investigates the development of social inequalities in multimorbidity among the middle-aged and older working population. Special attention is paid to whether differing time trends between socio-economic status (SES) groups have taken place, increasing or decreasing inequalities in multimorbidity.

Methods

The analyses are based on claims data of a German statutory health insurance company covering an observation period from 2005 to 2015. Multimorbidity prevalence risks are estimated using logistic generalized estimation equations (GEE) models. Predicted probabilities of multimorbidity prevalence are used to assess time trends in absolute social inequalities in terms of educational level, income, and occupational group.

Results

The prevalence risks of multimorbidity rose among all SES groups and social gradients persist throughout the observation period, indicating significantly higher multimorbidity prevalence risks for individuals with lower SES. Widening absolute inequalities are found among men in terms of educational level and among women in terms of occupational groups.

Conclusions

The increases in multimorbidity prevalence among the working population are accompanied by widening social inequalities, pointing towards a growing disadvantage for men and women in lower SES groups. The rising burden and the increasing inequalities among the working population stress the importance of multimorbidity as a major public health concern.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0815-z) contains supplementary material, which is available to authorized users.