In 1992, the National Institute of Health considered depression to be one of the potentially amenable factors involved in the pathways to disability and impaired well-being (1). Despite this, individual studies often demonstrate little use of appropriate health services and estimate low rates of treatment for any type of depression (1,2). This continues to occur even when depression is clearly recognized and accurately diagnosed in clinical practice (3).
This paper reviews the English language literature that describes
treatment-seeking rates and mediating factors among adolescents
and adults with depression. For the purposes of this paper, we use
the term depression to encompass all subtypes of depressive illness,
including both episodes and disorders. Where appropriate, we also
include data derived from those individuals with symptoms but with
no formal diagnosis of a depressive illness. Further, we incorporate
all measures of treatment seeking employed by the studies. Therefore,
a whole range of caregivers and modalities of treatment are included
within this papers definition of treatment. The purpose of
this review is twofold: 1) to determine the estimated overall rate
of treatment seeking for depression as reported in methodologically
sound studies and 2) to summarize those factors reported to influence
the likelihood of treatment seeking for depression.
The literature search for studies of treatment seeking among individuals with depression began with the following Medline Mesh headings: depressive disorders, therapy and depression, therapy. We identified 8040 citations, and these were then successively cross-referenced against the following Mesh headings: help seeking and mental health services. This search identified 15 and 54 citations, respectively. A second cross-reference between mental health services, utilization and Canada resulted in 40 additional citations. A preliminary review of the abstracts found that, of the 109 citations, 19 were potentially relevant to our literature review. Next, we did an additional search of the Psycinfo database and cross-referenced health care utilization against major depression, endogenous depression, and recurrent depression. Of the 125 citations listed, 25 appeared to be relevant to the project. In total, the 2 databases identified 44 citations; however, 6 were identified in both databases. Ultimately, 38 papers were identified for a detailed review. Prior to the methodological review, each study was photocopied, and the authors names and affiliations and the journal names were concealed from the reviewers.
Two reviewers, both with graduate-level training in epidemiology, conducted an independent methodological review of each paper to determine which of the 38 articles provided valid treatment-seeking estimates in persons with depression. We asked both reviewers to independently answer the following 4 questions:
1. Is the estimated rate or proportion of treatment seeking applicable to a defined population and not merely to a clinical group?
2. Did the study evaluate depression with a specific measure (diagnostic interview and clinical diagnosis)?
3. Was the study free of methodological problems that could render the study highly vulnerable to bias?
4. Did the measures of treatment seeking and depression prevalence use the same time interval? For example, if 1-year prevalence was examined, treatment seeking must have also been evaluated over a 1-year interval in the same study.
Health maintenance organizations and general populations, as well as demographic-specific rates, were accepted as representing defined populations.
Studies were excluded if they relied only upon self-report measures, administrative diagnostic codes, or symptom ratings in lieu of a diagnostic measure.
The employed measures of depression were to be credible, and no obvious vulnerability to bias of other sources, such as selection bias, was to exist.
Studies were accepted for inclusion in the review only if each of the above 4 questions could be answered in the affirmative. Overall, 17 papers were identified as being fundamentally methodologically sound and thus appropriate for inclusion in this study.
The studies incorporated in this review assessed different subcategories of depressive illness. Within the context of this paper, we categorize depressive illness according to 4 subtypes. These include major depression, minor depression, dysthymia, and generic depression. For the purpose of our review, we included the diagnosis of pervasive depression (14) in the category of major depression. In addition, we included the subtypes of subsyndromal depression and subthreshold depression in the category of minor depression. Several authors used the subcategory terms of subsyndromal depression (6) and subthreshold depression (7) to include various depressive entities that do not meet the diagnostic criteria for major depression. The remainder of this paper uses the term generic depression to categorize those studies that did not differentiate rates attributable to different subtypes of depression. This term also incorporates the findings from one study (11) that found treatment-seeking rates for affective disorders. This category in the study (11) included major depressive episodes, dysthymia, and manic episodes (in order of decreasing prevalence).
Overall Estimate of Treatment-Seeking Rates
In summary, the overall estimated rate for which individuals sought help for depressive episodes or disorders fell between 17.0% and 77.8%. This broad range incorporates the varied subcategories of depressive illness assessed. Ranges of treatment-seeking rates within the subcategories of depressive illness were also broad. Between 17.6% and 60.6% of individuals with minor depression sought treatment in the various studies (1,6,7,12). The literature also demonstrated that between 27.6% and 60.7% of individuals with a major depressive episode or disorder sought some form of treatment (1,2,57,9,1214). Angst and Merikangas noted that 77.8% of individuals with dysthymia sought help for symptoms (7). Finally, between 17.0% and 74.3% of individuals with generic depression sought treatment (3,4,6,8,10,11,1517). Some studies (1,6,12,15) also investigated the rates of treatment-seeking among individuals who had depressive symptoms but who did not meet the particular studys criteria for a diagnosis of depression. Excluding lifetime prevalence of treatment for depression, between 3.5% and 29.8% of individuals without a current or recent diagnosis of a depressive episode also sought help for depressive symptoms. In all studies, these individuals endorsed experiencing only some depressive symptoms (1,6,12,15).
Figure 1 (papers 1 to 17) illustrates
the treatment-seeking rates for different subtypes of depression
according to the studies publication years. A linear regression
line was fit to the major depression data, because this was the
most homogeneous diagnostic category. As expected, an initial data
analysis revealed that rates of treatment seeking increased as studies
assessed longer time periods over which treatment seeking took place.
In addition, 3 recent studies (6,7,13) specifically assessed treatment-seeking
rates for periods of time well beyond 12 months duration.
To control for this potential confounder, we refit the linear regression
line for the category of major depression without this particular
data. As seen in Figure 1, a similar
upward trend was apparent for both regression lines. The evidence
uncovered in this review suggests that treatment-seeking rates for
major depression have increased over the years
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