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Mental disorders are associated with enormous disability and cost to our society (1). To develop a national mental health care policy (2), accurate cross-sectional information on the number of people who need mental health services is required. Although this goal is well accepted, the optimal method to achieve it is controversial (3–6). In the last 25 years, the main approach for estimating the number of people in the community who need care for mental illness has been to provide prevalence estimates of common mental disorders based on the explicit criteria of an accepted diagnostic system (7). Cross-nationally, most individuals with a mental disorder diagnosis do not receive or perceive a need for treatment (1,8–11). From these findings, some leaders in the field of psychiatric epidemiology have suggested that a large proportion of individuals diagnosed with mental disorders may suffer from transient or mild symptoms that do not require treatment (5,6). Conversely, community surveys have repeatedly demonstrated that a significant proportion of individuals seek or perceive a need for treatment without meeting criteria for a mental disorder (12–15). These individuals could have a past mental disorder, a subthreshold mental disorder (16–20), or a disorder that was not assessed in the survey. Previous work suggests that these individuals could also benefit from treatment (12,21). In short, the presence of a DSM diagnosis is not a good measure of the need for treatment (5). Shapiro and others have suggested assessing need for treatment according to the following 3 measures: 1) the presence of a DSM disorder, 2) dysfunction in usual activities, and 3) increased distress on a continuous measure of distress (22). More recently, Bebbington and others (23) and Lehtinen and others (24) have suggested the use of clinicians to individually assess need for treatment on a case-by-case basis in epidemiologically representative samples. Increased attention has also recently been paid to self-perceived need for mental health treatment in the community (12,24–28). This concept takes into account theoretical models of HS. These models posit that individuals suffering from emotional problems pass through several stages prior to seeking help for emotional symptoms: 1) they experience symptoms, 2) they evaluate the severity and consequences of the symptoms, 3) they assess whether treatment is required, 4) they assess treatment feasibility and options, and 5) they seek or do not seek treatment (29). In considering these stages of HS, it becomes apparent that defining how many people in the community need mental health treatment depends on which stage of this HS process is used as the threshold to determine need. Our group and others have suggested that, when assessing how many people need help for emotional symptoms, it might be useful to examine self-perceived need for mental health treatment in addition to assessing who meets criteria for a mental disorder diagnosis (12,26,29). Previous studies have identified self-perceived need for treatment when respondents have either endorsed a need for mental health treatment or sought professional treatment (12,24–27). Cross-national surveys assessing perceived need for treatment have found the following results. First, the prevalence of perceived need for mental health treatment is much lower than the prevalence of meeting criteria for a mental disorder diagnosis (12,26,30). Second, self-perceived need for treatment, independent of meeting criteria for a mental disorder assessed in the survey, was found to be associated with increased distress and disability (28,30). The current study extends our previous work using the OHS and examines self-perceived need for mental health services in the CCHS 1.2. In comparison with the OHS, the CCHS 1.2 provides current information, a larger sample size, and a more comprehensive section on perceived need and quality of life. We had 3 specific objectives in our current study. First, we examined the prevalence and correlates of PN and HS. Second, we examined the relation between PN and (or) HS, DSM diagnosis, and disability. Finally, among the subsample of respondents with PN, we examined the types of treatment that the respondents felt they needed, together with barriers to HS. MethodsThe description of the CCHS 1.2 has been provided elsewhere (31). For the current analysis, we used the entire sample of survey participants (n = 36 816). Measures Help Seeking. Respondents indicating that they had seen a professional (that is, a psychiatrist, family doctor or general practitioner, other medical doctor, psychologist, nurse, social worker or counsellor, religious or spiritual advisor, or other) about their emotions, mental health, or use of alcohol or drugs in the past 12 months were categorized as “help seekers for mental health problems.” Perceived Need Without Help Seeking. Respondents endorsing the question “During the past 12 months, was there ever a time when you felt that you needed help for your emotions, mental health, or use of alcohol or drugs, but you didn’t receive it?” were categorized as “perceived need for mental health treatment.” All respondents with PN were asked further questions probing the types of help they thought they needed and their reasons for not receiving treatment. Sociodemographic Variables. Sex, age, ethnicity, immigrant status, marital status, education, household income, and receipt of social assistance were examined in relation to HS and PN. Mental Disorders. Past-year prevalence of DSM-IV mental disorders (32) was assessed with the CIDI (33,34). The following mental disorders were assessed: major depression, mania, panic attacks, social phobia, agoraphobia, alcohol dependence, and drug dependence. Suicide. Past-year suicidal ideation and attempts were measured by 2 separate questions: “Did you seriously think about committing suicide or taking your own life?” and “Did you attempt suicide or try to take your own life?” Chronic Physical Conditions. Respondents were asked whether they had been given a diagnosis by a health care professional for any of 21 specific chronic physical conditions (for example, diabetes, heart disease, and respiratory disease). Chronic was defined as lasting for at least 6 months. The number of chronic physical health conditions was dichotomized into zero or one or more, similar to previous analyses (12,26). Current Quality of Life. The CCHS 1.2 used the WBMMS (35) to assess psychological well-being. The WBMMS produces an overall psychological well-being score based on numerous questions assessing variables such as self- confidence, ambition, and happiness. A dichotomous psychological well-being variable was created to indicate high vs low psychological well-being, based on the median score for the WBMMS. The K10 (36) was used in CCHS 1.2 to measure distress. An overall distress score was generated by Statistics Canada, based on participants’ responses to 10 items asking about feelings such as nervousness and hopelessness. A dichotomous distress variable was created to indicate high vs low distress, based on the median score for the K10. Current disability was derived by totalling the number of days in the past 2 weeks that the respondent was in bed for all or most of the day owing to emotional problems, mental health status, or use of alcohol or drugs. This variable was dichotomized into zero vs one or more days of disability. Long-Term Disability. Respondents were asked whether a long-term physical health condition, mental condition, or health problem had reduced their amount or kind of activity “at home,” “at school,” “at work,” or “in other activities, for example transportation or leisure.” Possible responses were “never,” “sometimes,” or “often.” Respondents endorsing “never” for all areas of functioning were categorized as “not restricted,” and the remaining respondents were categorized as “restricted.” Social Supports. Four categories of social support, assessed according to several items from the MOS (37), were measured in CCHS 1.2: 1) informational support (availability of advice, guidance, and feedback), 2) tangible support (provision of material aid or behavioural assistance), 3) positive social interaction (availability of fun social relationships), and 4) affection (expressions of love and affection) (31). From the total score, dichotomous variables for each domain were created to indicate high vs low social support. Analytic Strategy We applied the appropriate statistical weights provided by Statistics Canada in all data analyses to ensure that the sample was representative of the Canadian population. A bootstrapping technique was used that incorporated multistage sample design information provided by Statistics Canada to produce 95%CIs (38). Logistic regression analyses were conducted to examine the correlates of PN or HS vs neither and PN vs HS (Table 1). The same analyses were repeated using multiple logistic regression adjusted for mental disorders. Next, we divided the sample into 4 mutually exclusive categories: 1) PN or HS and DSM diagnosis, 2) PN or HS no DSM diagnosis, 3) DSM diagnosis no PN or HS, and 4) neither PN or HS nor DSM diagnosis. Using multiple logistic regression, we examined the relation between PN or HS and DSM diagnosis (that is, one or more mood, anxiety, or substance use disorder) on a range of quality of life, disability, and suicide variables. Covariates in these regressions included sociodemographic and social support variables.
ResultsIn the whole sample, the prevalence of HS was 8.7% and the prevalence of PN was 2.9%. Table 1 illustrates the relation between PN and HS and a range of sociodemographic factors, quality of life variables, physical health conditions, and social support variables. Adjusting for psychiatric diagnoses reduced the strength of the associations; however, most associations remained significant. Among the subsample with PN, the 3 types of care most commonly felt to be required but not received were “therapy or counselling” (49.5%), “help for personal relationships” (21.6%), and “information on mental illness or treatment” (20.2%). Interestingly, only 7.7% of the subsample endorsed “medication.” The 3 most common reasons for not seeking care when there was a perceived need were “preferred to manage [emotional problems] by self” (35.5%), “did not get around to it [seeking treatment]” (19.0%), and “did not know how to get help” (15.7%). The prevalences of PN or HS only, one or more DSM diagnoses only, and PN or HS plus at least one DSM diagnosis were 5.3%, 8.8%, and 6.0%, respectively. Table 2 demonstrates that individuals with PN or HS and at least one DSM-IV diagnosis had the greatest levels of disability, distress, and suicidal behaviour, compared with individuals having either PN or HS or a DSM diagnosis only or neither PN nor HS nor a DSM diagnosis. Respondents with PN or HS only or a DSM diagnosis only had similar levels of distress; however, these levels of distress were substantially higher than levels among those with neither PN nor HS nor a DSM diagnosis.
DiscussionThis study is the first to provide current, nationally representative information about the prevalence and correlates of PN and HS in the Canadian general population. The findings are consistent with previous literature (12,26,30) in several ways. First, the overall prevalence of PN or HS in this sample was 11.6%, which is similar to previous reports from the OHS (11.7%) (39) and Australia (13.8%) (25) and falls in the middle of the range of prevalence estimates noted in other countries (7.0% to 19.4%) (24,27,39). Second, the presence of PN or HS independent of the presence of DSM-IV diagnosis assessed in the survey was associated with increased levels of distress, suicidality, and short- and long-term disability (12). Finally, respondents meeting criteria for a mental disorder but without PN or HS (8.8% of the sample) displayed higher levels of disability, distress, and suicidal behaviour, compared with respondents having no diagnosis and no PN or HS. Overall, the current study shows that the group with PN or HS only (5.3%), the group with a DSM diagnosis only (8.8%), and the group with either PN or HS plus a DSM diagnosis (6.0%) had elevated levels of distress, disability, and suicidal ideation. This finding suggests that approximately 20.1% of Canadians were in need of mental health services at the time of the CCHS 1.2. This prevalence rate is slightly higher than reported figures. For example, a recent survey in Montreal found that a clinician-based assessment of need for treatment yielded a prevalence rate of 18% in the adult population (40). In the US, Narrow and others reported a prevalence rate of 18.1% (41), based on revised prevalence estimates obtained by using clinical significance criteria of the US NCS and the US ECA Study. Using the latter US survey, Shapiro and others estimated that 14.0% of the population needed services, according to the combined presence of DSM diagnosis, role impairment, and high distress (22). In a Finnish sample, 14.5% and 19.6% of men and women, respectively, were categorized as needing mental health treatment, according to clinician assessment (24). Lastly, Bebbington and others reported 10.1% of a British community sample to be in need of mental health services, also according to clinician assessment (23). The extent to which these intercountry differences result from methodological differences, compared with true differences, is unknown. We have also extended the literature by demonstrating that ethnicity, immigrant status, and social supports are important correlates of PN and HS. These findings suggest that health policy-makers need to consider ethnicity and immigrant status in designing strategies to improve access to services and treatment for individuals with mental disorders (42,43). Unlike previous studies (12,26), we found significant differences between PN and HS on a range of variables. The larger sample size in the current investigation, compared with previous surveys, allowed for greater power to detect differences between PN and HS. For example, substance use disorders were less likely to be associated with HS, compared with PN. These findings imply that it may be especially important to target relevant information about appropriate treatment and how to access it to individuals with substance use disorders. The most common unmet need endorsed by respondents in the current survey was the need for counselling, whereas unmet need for medications was endorsed by only 8% of those with PN. This finding is consistent with a previous study examining perceived need in Australia. Meadows and others (30) explain that the most common professionals to be contacted for emotional symptoms are primary care physicians, who are more likely to be able to meet the need for medications but may be less skilled in providing psychological treatments, compared with psychiatrists or psychologists. Increased access to psychotherapy should be considered for those who perceive a need for it. In combination with previous literature, our findings suggest that policy-makers need to consider PN and HS in delineating the number of people who require treatment for emotional symptoms. Although self-perceived need for treatment or seeking treatment may be affected by a range of complex social, ethnic, and psychopathology variables (for example, psychotic illness may affect insight), there is clear evidence that an individual with a perceived need for treatment or an individual who has sought help will have elevated levels of distress, compared with the control group, and may benefit from treatment. Together with other studies demonstrating that a significant proportion of individuals who seek treatment for emotional symptoms do not receive adequate or quality care (44,45) or drop out of treatment (46), we suggest that health care policy-makers need to make improved quality of care (including therapy, medications, and self-help groups) a priority for those respondents who have PN or HS. In the current investigation, 50% of individuals with PN wanted to manage problems on their own; therefore, increased public awareness of self-help books that have demonstrated efficacy in controlled trials (47) should be considered as a method of improving care for these individuals. Our survey was limited because the assessment of HS was based on self-reported information. Although this is the best available method in community surveys, there is evidence that self-reported HS behaviour may be affected by recall bias (48). Another limitation was the brief assessment of PN. In this regard, Meadows and others have developed the PNCQ (25), a reliable instrument measuring PN. Future surveys in Canada may consider using the PNCQ to provide more detailed information of PN in Canada. In conclusion, the current study highlights the importance of identifying self-perceived need for mental health services when delineating who needs help for emotional symptoms in Canada. Combining self-reported need for treatment with objective measures (such as the presence of a DSM diagnosis) led us to estimate that 20.1% of Canadians need mental health services. Funding and SupportOur research and analysis are based on data produced by Statistics Canada. The opinions expressed do not represent the views of Statistics Canada. The CIHR and the Manitoba Health Research Council (establishment grant to Dr Sareen) provided funding support for the current investigation. AcknowledgementWe thank Mrs Shay-Lee Belik for her statistical work related to this manuscript. References1. The WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health surveys. JAMA 2004;291:2581–90. 2. Kirby M. Mental health, mental illness, and addiction. Canadian Psychiatric Association Annual meeting; 2003 October 10–31; Halifax (NS). 3. Mechanic D. 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Rhodes AE, Lin E, Mustard CA. Self-reported use of mental health services versus administrative records: should we care? Int J Methods Psychiatr Res 2002;11:125–33. Author(s)Manuscript received and accepted May 2005. 1. Assistant Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. 2. Professor, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba. 3. Graduate Student, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba. 4. Graduate Student, Department of Psychology, University of Manitoba, Winnipeg, Manitoba. 5. Assistant Professor, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba. Address for correspondence: Dr J Sareen, PZ430–771 Bannatyne Avenue, Winnipeg, MB R3E 3N4 e-mail: sareen@cc.umanitoba.ca
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