Why do so many people with psychological problems fail to seek treatment?

The prevalence of mental illness:  Throughout the world, mental illness is much more prevalent than is commonly recognized.  In the United States research suggests that about half of the population will experience a mental disorder of some kind at some time in their life; specifically, 46.4% will experience at least one disorder, 27.7% two, and 17.3% three or more (Kessler et al, 2005).  World wide, a World Health Organization study found that 26% of persons surveyed reported symptoms of a mental illness in the previous 12 months (Andrade et al, 2013).

The problem of low utilization: Despite these high prevalence rates, a surprisingly small proportion of individuals suffering from a mental disorder receive professional attention. Treatment rates vary, ranging from approximately 2% in less developed countries to only 18% in developed countries in the west such as the US (Wang et al, 2007). In Singapore only 5.9% of those with a mental disorder sought any professional help (Ng et al 2003).  The shocking and tragic fact is that from 82% to 98% of individuals the world over suffering from mental problems do not receive treatment.

Why is treatment utilization so low worldwide? What are the specific barriers to receiving mental health treatment? If you take a minute or so to guess the answer, I think you will find the results of actual research addressing these questions rather surprising.

The Unexpected Answer from Scientific Research

Fortunately the answer to the question of why treatment is so infrequent has been provided by a World Health Organization study involving over 100,000 adults in 24 countries  (Andrade et al, 2013). From this large sample individuals who were determined by standardized tests to have a mental disorder at some time in the previous 12 month period but reported having received no treatment during that period were asked why they did not seek treatment.  The frequency with which each of the  top ten reasons given are summarized numerically in Table 1 and graphically in Fig. 1.  Unfortunately Andrade et al did not provide a frequency for low perceived need for their entire sample, so in Table 1 a range was used of 65 to 75 % and for Fig. 1 a value of 70% was taken as an approximate value in order to plot relative frequencies of each reason.

Table 1. Ranking of frequency of reported reasons for not seeking treatment by individuals who had a DSM-IV disorder in the previous 12 months.  (Based on Table 3 in Andrade et al 2013 with sample size altered in order to rank frequencies.)

Figure 1. Graphical representation of the relative frequencies of the various reasons given for not seeking treatment as detailed in  Table 1.

In order of decreasing frequency the reasons for not seeking treatment were:

1.     Low perceived need was the most frequently endorsed reason. Even among severe cases “low perceived need was the most commonly reported barrier to treatment in 15 of the 25 surveys” where it ranged from 56.4% to 99.3% ... “ (Andrade et al 2013). In less severe cases e.g. moderate to mild, low perceived need was given as a reason even more frequently.Also perceived need was influenced by economic level.  For example, in India which is has a large low and lower middle income population, 99% of the respondents said that the reason for not seeking treatment was they did not think there was a need for it. 

2.   A desire to handle the problem by oneself was the second most common reason.  More than half of those not receiving professional help wished to manage their mental health problem on their own and did not wish to go to a mental health professional.  This is extremely important and relatively new information which has profound implications for how to best help individuals with mental health problems.  It suggests that greatly increased emphasis should be placed on helping such individuals help themselves. For example, the mental health community could help by providing more and better public psychoeducation, and more access to the many effective self-help books which are available. Another important but increasingly recognized source of help are self-help groups.

3.   The perception that their problem was not severe. Approximately 1/4 of untreated mentally ill did not see it as severe enough to seek treatment. Perhaps a public education program educating those with mental disorders about the effect of their mental disorder on their families and work colleagues would help increase awareness that their mental illness is causing not only distress to themselves but to their loved ones and friends.

4.      The perception that their problem would get better on it own.

5.      Financial reasons.  The relative low ranking of financial reasons, number 5 out of 10 is surprising because many have assumed that this was one of the most important reasons (Albee, 1999).  However there was evidence that the frequency of this reason depended on the economic wealth of the country being sampled and the financial status of the respondent.  That is cost is still an important factor for many, especially those living in poverty.

6.      Perceived ineffectiveness. The relatively low ranking of this variable suggests that the vast majority of persons with mental health problems believe that mental health treatment is effective. And it is important to note that this sample was for those who did not seek mental health treatment.

7.      Availability. The relatively low ranking of availability again was a very surprising result given the generally held belief that there is a shortage in mental health services and that there never will be enough mental health services to satisfy the need (Albee, 1999).   Again in low socioeconomic countries lacking facilities, this would be an important barrier to treatment.

8.      Stigma. The low ranking of stigma was another surprising result of this study since stigma has often been cited as a reason for not seeking help at least in the past (Brown et al 2012). Still in some less advanced countries, attitudes to mental health are relatively negative and fear of stigmatization is a significant barrier. Public education programs about mental illness have been shown to be immensely powerful in improving the public’s attitudes and reduce stigmatization.

9.      Inconvenient

10.    Transportation difficulty

Implications of study on public health.

The study by Andrade et al discussed here is the largest and most representative study to date on barriers to receiving mental health treatment.  It extends and confirms previous smaller scale research on such barriers (Mojtabai  et al, 2010; van Beljouw et al, 2010; Wang et al, 2010.  The results of these studies have profound implications for how to best help individuals with mental health problems.

Perceived need and desire to handle problem by oneself. These were by far the two most frequently given reasons given for not seeking treatment. Compared to financial reasons and fear of stigmatization, they were endorsed much more frequently. While unexpected, similar results have been obtained by researchers (Mojtabai  et al, 2010; van Beljouw et al, 2010; Wang et al, 2010).  Despite this, the most commonly believed causes for low treatment rates are financial concerns about the cost and fear of stigmatization. Even among the mental health community, the perceived need for individuals who wish to do it on their own receive scant attention.

Consistent with this view, in a previous post entitled “What stops people with mental health issues from seeking treatment?” (http://www.psychologymatters.asia/article/64/what-stops-people-with-mental-health-issues-from-seeking-treatment.html#sthash.EqZAdb5g.dpuf), I myself focused entirely on stigmatization as did Brown et al (2010) who only investigated stigmatization as a cause of low treatment rates. 

Fortunately Andrade et al in the study described here compared a variety of possible reasons for low treatment utilization and discovered that there were several other important reasons besides stigmatization.  Therefore there should be greatly increased education of the public and mental health policy makers about the wider range of reasons revealed by the Andrade study.

Also further research is required to better understand the source and nature of low perceived need and desire to handle problem privately. For example is the low perceived need due to denial that one has a mental illness and if so why does this denial occur? It does not seem to be fear of stigmatization since stigmatization itself was endorsed by only 7.7% of persons not receiving treatment.

The second most frequently endorsed reason: the desire to cope with the mental disorder independent of professional help is a surprising and seldom recognized barrier to treatment. One practical implication is that greatly increased attention should be directed to helping such individuals help themselves. For example, the mental health community could put increased emphasis on providing more and better quality public psychoeducation, and increase access to the many effective self-help books which are available. Another important and increasingly recognized source of self-help are self-help groups.  The mental health community could increase its role in helping those with a psychological disorder getting into the appropriate self-help group.

Less frequent but still extremely important reasons.  Although low perceived need and a desire to manage psychological problems on their own were by far the most frequently endorsed reasons for not seeking treatment in this study, the remaining eight barriers still deserve more research and attention with respect to public health policy. These include: the belief that the disorder was not severe or would get better on its own; financial reasons; perceived ineffectiveness; availability; and fear of stigmatization.

General conclusion.  Although Albee’s (1999) vigorous contention that prevention of mental illness should be the ultimate goal still holds, recent research on barriers to receiving mental health services indicates that in the short term there is plenty more that can be done to make much better use of existing mental health services and reduce human suffering.

References

Albee, G. W. (1999). Prevention, not treatment, is the only hope. Counselling Psychology Quarterly, 12(2), 133-146. (see p. 138 “Psychotherapy is a luxury for the affluent.”

Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E.,  AlHamzawi, A., . . . Kessler, R. C. (2013). Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychological Medicine / FirstView Article, pp 1-15.nd Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.

Brown C., Conner, K.O., Copeland, V.C., Grote, N., Beach, S., Battista, D, & Reynolds III, C.F. (2010). Depression, stigma, race, and treatment seeking behavior and attitudes. Journal of Community Psychology, 38, 350–368. doi:10.1002/jcop.20368.

Mojtabai, R., Olfson, M., Sampson, N. A., Jin, R., Druss, B., Wang, P. S., . . . Kessler, R. C. (2010). Barriers to mental health treatment: Results from the National Comorbidity Survey Replication. Psychological Medicine, 41(8), 1751-1761.

Ng, T. P, Fones, C. S., Kua, E. H. (2003). Preference, need and utilization of mental health services, Singapore National Mental Health Survey. Australian and New Zealand Journal of Psychiatry. 37(5):613-619.

van Beljouw, I., Verhaak, P., Prins, M., Cuijpers, P., Penninx, B., & Bensing, J. (2010). Reasons and determinants for not receiving treatment for common mental disorders. Psychiatric Services, 61(3), 250-257.

Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Borges, G., Bromet, E. J., . . . Wells, J. E. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. The Lancet, 370(9590), 841-850.

Copyright © 2013 by Dr. Brian S. Scott