Gender and outpatient mental health service use
Introduction
The purpose of this study is to describe gender differences in the use of outpatient mental health services and to identify potential determinants of this use. We hypothesize that type of mental disorder lies in the causal pathway between gender and use of outpatient mental health services and mediates much of the gender-use relationship despite control for social and economic factors. Gender differences in health are often characterized as women living longer and experiencing greater morbidity than men do. However, gender differences in morbidity vary with specific health conditions and phases of life (Macintyre, Hunt, & Sweeting, 1996). Likewise, gender differences in health service use are more complex, (Cleary, Mechanic, & Greenley, 1982; Macintyre et al., 1996; Mustard, Kaufert, Kozyrskyj, & Mayer, 1998). Specific types of health problems and services need to be investigated within the broader social context for a better understanding of when and why gender differences in use occur.
Approximately 6–10% of the population in North America make an outpatient mental health visit annually (Bland, Newman, & Orn, 1997; Kessler et al., 1997; Lin, Goering, Offord, Campbell, & Boyle, 1996; Regier et al., 1993). Studies consistently find that women are about twice as likely as men to make an outpatient mental health visit whether self-reported (Katz et al., 1997b; Leaf et al., 1985; Lin et al., 1996) or record-based investigations (Tataryn, Mustard, & Derksen, 1994; Watts, Scheffler, & Jewell, 1986; Wallen, Roddy, & Meyers, 1986). Potential explanations for these differences are reporting biases, attitudinal differences or variations in levels of need. Systematic differences in reporting by gender appear to be small. Gender differences in use are consistent across self-reported and record-based studies at an aggregate level. In addition, there is little evidence to indicate that women are more likely to report their use of mental health services than men at the individual level (Golding, Gongla, & Brownell, 1988; Taube, Schlenger, Rupp, & Whitmore, 1986). The explanation that women are more positively oriented towards seeking help for mental health problems has been investigated (Horwitz, 1977; Kessler, Brown, & Broman, 1981a; Leaf & Bruce, 1987). However, attitudinal measures have not been well developed and past use may influence current attitudes. In prospective studies, attitudinal measures are not strongly related to use (Cleary et al., 1982; Greenley & Mechanic, 1976). In contrast, measures of need are robust predictors of health service use (Andersen, 1995; Cleary, 1989). It is puzzling, then, why gender differences in use of outpatient mental health services persist despite control for mental disorder (Leaf et al., 1985; Gallo, Marino, Ford, & Anthony, 1995; Katz, Kessler, Frank, Leaf, & Lin, 1997a; Shapiro et al., 1984).
We argue that a critical piece has been missing from the explanation, namely, the impact of the different types of mental disorder that men and women experience. Historically, studies of gender and mental illness have relied upon unidimensional measures of mental health problems, e.g., psychological distress, to bypass the problems with classification and measurement of mental disorder (Dohrenwend, 1998). With the evolution of diagnostic criteria and instruments, studies have found that women are not more likely than men to suffer from mental illness (Canino et al., 1987; Kessler et al., 1994; Robins, Locke, & Regier, 1991). Nevertheless, men and women do vary in the types of mental disorders they experience. Women are about twice as likely to have mood and/or anxiety disorders (Mood/Anx) whereas men are about four times more likely to have substance use disorders and/or antisocial behaviours (Subs/Asb) (Offord et al., 1996; Robins et al., 1991). The use of outpatient mental health services varies according to these types of mental disorder with stronger associations typically occurring for those with mood or anxiety disorders (Katz et al., 1997b; Shapiro et al., 1984).
One complication in the study of gender, type of mental disorder and use is how to deal with concurrent mental disorders. Concurrent mental disorders are common (Boyd et al., 1984; Kessler et al., 1994; Offord et al., 1996) and related to use (Kessler et al., 1994; Kessler et al., 1996). However, the patterns of co-occurrence are distinct. The disorders within Mood/Anx occur together more frequently than with other disorders. The same is true of Subs/Asb (Bland, Newman, Russell, & Orn, 1994; Canino et al., 1987; Kessler, 1995; Regier et al., 1990; Ross, 1995). There are empirical reasons, therefore, to group mood and anxiety disorders together (Mood/Anx) and to group substance use disorders with antisocial behaviours (Subs/Asb).
There are also conceptual reasons for grouping type of mental disorder in this manner. Subs/Asb are defined in terms of behaviours (American Psychiatric Association (1987), American Psychiatric Association (1994)) which may lead to the perception that these disorders are under a greater degree of voluntary control than other illnesses (O’Brien & McLellan, 1996). Coupled with the historic lack of medications to treat Subs/Asb (Shuckit, 1996) and the need for legal containment of some antisocial behaviours, many may believe that Subs/Asb are characterological in nature and not amenable to treatment. Seeking help would seem to serve little purpose and may be perceived as harmful. Therefore, the need to deny, hide or minimize these problems would be magnified. Providers may have reinforced such perceptions. For example, it has been suggested that the specialty sector has increased barriers to treatment for persons with substance use disorders by making them “admit” to their addictions (McCrady & Langenbucher, 1996).
In contrast, seeking help for the debilitating somatic symptoms of Mood/Anx and being prescribed medication may be more acceptable to individuals (Goering, Lin, Campbell, Boyle, & Offord, 1996; Kouzis & Eaton, 1994; American Psychiatric Association, 1987; American Psychiatric Association, 1994). Being prescribed a medication conveys the powerful message that a biological defect exists that can be corrected. Medications for treating the symptoms of Mood/Anx have been available for some time (Lydiard, Brawman-Mintzer, & Ballenger, 1996; Thase & Kupfer, 1996) and these medications are actively marketed by drug companies (Nikelly, 1995).
In order to examine gender, type of mental disorder and the use of outpatient mental health services more fully, a number of methodological issues must be addressed. First, while most studies have included gender in their analyses, they have not focussed specifically on gender, thereby obscuring the effects of potentially modifiable social structures and processes (Walsh, Sorensen, & Leonard, 1995). Second, unidimensional measures of mental illness have often been studied instead of type of mental disorder. A unidimensional strategy neglects the possibility that a variety of health outcomes arise from gender differences in endowments and experiences (Aneshensel, Rutter, & Lachenbruch, 1991; Dohrenwend & Dohrenwend, 1974). When type of mental disorder has been included (Katz et al., 1997b; Leaf et al., 1985; Marino, Gallo, Ford, & Anthony, 1995), its impact upon gender differences in use has not been investigated.
Third, gender differences in socioeconomic position and financial barriers to care may affect use. Accordingly, one's age, marital status, education, labour force activity, personal and household income may all bear upon gender and use. Most studies have been conducted in the United States where insurance coverage is not universal and therefore, those who are ill may be denied access to treatment on the basis of their inability to pay. A Canadian setting virtually removes this issue as the majority of health services are covered under provincial insurance plans. Previous studies have not always included comprehensive measures of socioeconomic position. In particular, the participation of many women in the labour force makes personal socioeconomic status an important measure to study (Arber, 1991).
Fourth, a large representative sample is necessary for the precise study of variations in use according to gender, type of mental disorder (including no disorder) and social and economic factors. Finally, a series of steps, described in the analyses below, must be followed to demonstrate whether type of mental disorder mediates the gender-use relationship (Baron & Kenny, 1986; Holmbeck, 1997; Rhodes, Lin, & Streiner, 1999).
Section snippets
Study design and sample
The source of data for this study is the Mental Health Supplement (MHS) to the Ontario Health Survey (OHS), a cross-sectional household survey conducted in Ontario, Canada, 1990–1991 (Boyle et al., 1996; Ontario Ministry of Health, 1995). The MHS incorporated a population-based multi-staged stratified cluster sampling design (Ontario Ministry of Health, 1992). The net response, taking into account the initial response in the OHS (88.1%) and follow-up response within the MHS (76.5%) was 67.4%.
Analyses
Several conditions must be met in order to assess whether type of mental disorder appears to mediate the gender-use relationship. Significant associations must be present between: (a) gender and use, (b) type of mental disorder and use and (c) gender and type of mental disorder. A change in the magnitude of the association between gender and use must occur when type of mental disorder is controlled and after the effects of other variables are taken into account. The relationship between type of
Sample characteristics
The gender distribution was equivalent. When age was divided into quintiles, no marked gender differences were apparent (). Nor were there differences in terms of marital/living arrangement (). Men and women differed in their main activities (), with the most obvious gender differences being that men were more likely to work for pay (77.6 vs. 61.6%) and women were more likely to be homemakers (24.7 vs. 0.1%). The relationship between
Discussion
This study shows that type of mental disorder influences the gender-use relationship, particularly Mood/Anx. While Mood/Anx appears to mediate the gender-use relationship, the effect is weaker than hypothesized as only 26% of the gender-use relationship is explained.
The results also suggest that Mood/Anx is a direct determinant of overall use. First, the association between Mood/Anx and use is large. Second, when each variable is removed from the final model to examine its impact on the
Acknowledgements
This study was supported through a Health Research Personnel Development Program Fellowship provided by the Ministry of Health, Ontario. The authors would like to thank Drs. Paul Links and Cameron Mustard for their helpful comments in the preparation of this manuscript.
References (74)
Class, paid employment and family rolesMaking sense of structural disadvantage, gender and health status
Social Science and Medicine
(1991)- et al.
Gender differences in healthAre things really as simple as they seem?
Social Science and Medicine
(1996) - et al.
The influence of patient and physician gender on prescription of psychotropic drugs
Journal of Clinical Epidemiology
(1992) - et al.
Myths about the treatment of addiction
Lancet
(1996) DSM-III-R alcohol abuse and dependence and psychiatric comorbidity in OntarioResults from the Mental Health Supplement to the Ontario Health Survey
Drug and Alcohol Dependence
(1995)- et al.
The role of gender-related processes in the development of sex differences in self-evaluation and depression
Journal of Affective Disorders
(1993) Reliability and validity studies of the WHO–Composite International Diagnostic Interview (CIDI)A critical review
Journal of Psychiatric Research
(1994)- American Psychiatric Association. (1987). Diagnostic and Statistical Manual Mental Disorders (Revised). DSM-III-R., 3R...
- American Psychiatric Association. (1994). Diagnostic and statistical manual mental disorders. DSM-IV (3rd ed.)....
Revisiting the behavioral model and access to medical careDoes it matter?
Journal of Health and Social Behavior
(1995)
Social structure, stress and mental healthCompeting conceptual and analytic models
American Sociological Review
The moderator–mediator variable distinction in social psychological researchConceptual, strategic, and statistical considerations
Journal of Personality and Social Psychology
Help-seeking for psychiatric disorders
Canadian Journal of Psychiatry
Epidemiology of psychiatric disorders in edmontonPhenomenology and comorbidity
Acta Psychiatrica Scandinavica Supplementum
Exclusion criteria of DSM-III. A study of co-occurrence of hierarchy-free syndromes
Archives of General Psychiatry
Mental health supplement to the Ontario Health SurveyMethodology
Canadian Journal of Psychiatry
The prevalence of specific psychiatric disorders in Puerto Rico
Archives of General Psychiatry
Sex differences in medical care utilizationAn empirical investigation
Journal of Health and Social Behavior
Difficult-to-recruit respondents and their effect on prevalence estimates in an epidemiologic survey
American Journal of Epidemiology
A psychosocial perspective on the past and future of psychiatric epidemiology
American Journal of Epidemiology
Social and cultural influences on psychopathology
Annual Review of Psychology
Sex, marital status, and age as social selection factors in recent psychiatric treatment
Journal of Health and Social Behavior
Filters on the pathway to mental health care, II. Sociodemographic factors
Psychological Medicine
Psychiatric disability in Ontario
Canadian Journal of Psychiatry
Feasibility of validating survey self-reports of mental health service use
American Journal of Community Psychology
Social selection in seeking help for psychological problems
Journal of Health and Social Behavior
Toward terminological conceptual and statistical clarity in the study of mediators and modernatorsExamples from the child-clinical and pediatric psychology literature
Journal of Consulting and Clinical Psychology
The pathways into psychiatric treatmentsome differences between men and women
Journal of Health and Social Behavior
Mental health care use, morbidity, and socioeconomic status in the United States and Ontario
Inquiry
The use of outpatient mental health services in the United States and OntarioThe impact of mental morbidity and perceived need for care
American Journal of Public Health
Sex differences in psychiatric help-seekingEvidence from four large-scale surveys
Journal of Health and Social Behavior
Reply to Gove and Swafford
Social Forces
Epidemiology of psychiatric comorbidity
Differences in the use of psychiatric outpatient services between the United States and Ontario
New England Journal of Medicine
Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey
Archives of General Psychiatry
The epidemiology of co-occurring addictive and mental disordersImplications for prevention and service utilization
American Journal of Orthopsychiatry
Cited by (109)
Trauma, Post-Traumatic Stress Disorder, and Treatment Among Middle-Aged and Older Women in the Nurses’ Health Study II
2022, American Journal of Geriatric PsychiatryCitation Excerpt :The WMH study described above, for example, found that only about half of individuals with lifetime PTSD in high-income countries received some kind of mental health treatment, though this estimate was not reported by country.5 This difference is likely due to fact that our sample is of women only, who tend to be more likely to access treatment compared to men,30,31 and the fact that our respondents have all had training in healthcare or currently work in healthcare. Despite higher treatment uptake or reporting in our sample, a treatment gap persisted and was largest among women with occupational trauma, for whom over half with PTSD went untreated.
Who comes to a self-help depression prevention website? Characteristics of Spanish- and English-speaking visitors
2021, Internet InterventionsCitation Excerpt :Although not all studies find differences in utilization rates for mental health services by gender (Gagné et al., 2014), there is some evidence that women may use mental health services at higher rates than men. For example, Rhodes et al. (2002) report that the odds of women using outpatient mental health treatment were some 70% higher than that of men. Wells et al. (1985) report that women were twice as likely as men to use prescription medication.
Predictors of behavioral health service utilization in a medicaid enrolled sample of emerging adults
2020, Children and Youth Services ReviewEffectiveness of manualized case management on utilization of evidence-based treatments for children and adolescents after maltreatment: A randomized controlled trial
2017, Child Abuse and NeglectCitation Excerpt :Unfortunately over half of participants who indicated they no longer perceived any need for treatment also declined to take part in the in depth clinical interview at follow-up resulting in numbers too low for the respective analyses. The literature is unclear in the effect of gender on mental health service use with findings contradictory to ours such as in Briggs-Gowan, Horwitz, Schwab-Stone, Leventhal, and Leaf (2000) who found male gender to be predictive of service use in children and adolescents and findings in line with ours showing higher rates of service use for girls (Rhodes, Goering, To, & Williams, 2002). Results on placement also have been contradictory in past research with Garcia and Courtney (2011), Garland and Besinger (1997) and Garland, Landsverk, and Lau (2003) showing less service use and Burns et al. (2004) and Sainero, Bravo, and del Valle (2014) showing more, suggesting that other mediating or moderating factors may have not been identified.