Economic crisis and mental health in Portugal:

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1 Economic crisis and mental health in Portugal: Preliminary results of the national mental health survey follow-up Gulbenkian Forum on Mental Health, November, 216 José Miguel Caldas de Almeida Ana Antunes Manuela Silva

2 National Mental Health Survey (WMHS Initiative) Carried out in in a sample representative of the adult Portuguese population In order to estimate: o the prevalence and severity of psychiatric disorders o Psychiatric and physical comorbidity o the use of health services and of psychotropic drugs o Prevalence and intensity of disabilities o Distribution by socio-demographic and economic variables o Risk and protective factors

3 Prevalence of any mental disorder in the last 12 months in European countries (WMHS Initiative) Northern Ireland Portugal France Netherlands Belgium Bulgaria Spain Italy Romania Adapted from Wang et al, 211

4 Treatment gap in serious mental disorders (WMHS Initiative) Countries Propor;onal treatment of serious 12-month disorders (%) Belgium 6.9 Bulgaria 31. France 48. Germany 4. Italy 51. Netherlands 5.4 Northern ireland 72.8 Portugal 66.4 Spain 58.7 Adapted from Wang et al, 2

5 MH Crisis impact study Funded by the EEA Grants; To obtain a new understanding of the effects of the economic crisis in Portugal on mental-ill health of the populations, determinants of mental disorders, and use of mental health services; To propose new policies, programmes and interventions aimed at the reduction of health inequalities and mental health problems linked with the crisis.

6 MH Crisis impact study Methods Part I Follow-up study in 215 of the national mental health survey: o In a probability sub-sample of respondents, over-sampling those with a history of mental disorder o Including modules of the CIDI-SC, 3 days symptoms, use of services and psychotropic drugs, work/employment, social support, finances and community involvement Part II - In-depth local case-studies, based on focus groups and semi-structured interviews with key actors in primary care services located in regional contexts specially affected by the crisis.

7 Crisis impact on mental health study Sample 28 n=259 29% Not found/ Moved/ Migrated (n=595) 21% Refused /not completed(n=432) 6% Deceased/ Severely disabled (n= 121) 215 n=911

8 What changed from 28 to 215 Professional Status 7 Professional status in 28 and Working Looking for job Others

9 What changed from 28 to 215 Economic situation Self-reported change in income (last 5 years) Reported reasons for change in income % Increased Equal Decreased Cuts in salary or Unemployment Changed job Re;rement Other pension

10 What changed from 28 to 215 Financial Deprivation 4 Perceived financial deprivation %

11 What changed from 28 to 215 Prevalence of mental health problems (K-) 35 Mental health problems in 28 and 215 (Kessler-) Mild Moderate Severe Any psychological distress 28 (n=562) 215 (n=911)

12 What changed from 28 to 215 Increase of mental health problems (K-) according to gender 2 18 Increase of mental health problems (k-) from 28 to Men Women

13 What changed from 28 to 215 Increase of mental health problems (K-) according to age group Increase of mental health problems (k-) according to age group from 28 and >

14 What changed from 28 to 215 Suicidal behaviour Idea[on Plan A]empt 2.1% 1.9%.5%.7%.3%.4%

15 Factors in 28 associated with mental health problems (K-) in 215 Multivariate analysis Gender Men 1 OR p-value Women Educa;on (years).91 <.1 Severity Severe 1 Moderate Mild.23 <.1 None.24 <.1 Suicidal idea;on 3.55 <.1 Disability (WHODAS) Variables considered in the mul[variate model: age; gender; educa[on; presence of any mental disorder or any physical disorder; severity; suicidal idea[on; suicidal planning; household income; occupa[on; marital status; professional status; self-perceived socioeconomic status; financial depriva[on; disability

16 Sociodemographic characteristics and mental health problems Age 2 Age groups and mental health problems(k-) K-: p<.5*

17 Sociodemographic characteristics and mental disorders Age 15 Age groups and mental health problems (MDE and GAD).9 % 6.7 MDE GAD MDE: p<.5* GAD: p>.5

18 Sociodemographic characteristics and mental health problems Gender Gender and mental health problems (K-) Men Women K-: p<.5*

19 Sociodemographic characteristics and mental disorders Gender 15 Gender and mental health problems (MDE and GAD) 9.1 % MDE GAD Men Women MDE: p<.5* GAD: p>.5

20 Sociodemographic characteristics and mental health problems Marital Status 2 18 Marital status and mental health problems (K-) Single Married Divorced, Widow K-: p<.5*

21 Sociodemographic characteristics and mental disorders Marital Status 15 Marital status and mental health problems (MDE and GAD) MDE GAD Single Married Divorced, Widow MDE: p<.5* GAD: p<.5*

22 Sociodemographic characteristics and mental health problems Education Education and mental health problems (K-) No educa[on and primary Basic Secundary University K-: p<.5*

23 Sociodemographic characteristics and mental disorders Education Education and mental health problems (MDE and GAD) 7.3 MDE 5.4 GAD No educa[on and primary Basic Secundary University MDE: p<.5* GAD: p<.5*

24 Sociodemographic characteristics and mental health problems Professional Status 25 Professional status and mental health problems (K-) Working Looking for job Others K-: p<.5*

25 Sociodemographic characteristics and mental disorders Professional Status Professional status and mental health problems (MDE and GAD) MDE GAD Working Looking for job Others MDE: p<.5* GAD: p>.5

26 Factors associated with mental health problems during the economic crisis o Financial Deprivation o Perceived Social Status o Social Support o Community Involvement o Disability

27 Factors associated with mental health problems in 215 Financial deprivation 25 Financial deprivation and mental health problems (K-) More or enough Not enough K-: p<.5*

28 Factors associated with mental disorders in 215 Financial deprivation 15 Financial deprivation and mental health problems (MDE and GAD).9 % 6.4 MDE GAD More or enough Not enough MDE: p<.5* GAD: p<.5*

29 Factors associated with mental health problems in 215 Types of financial deprivation 3 Types of financial deprivation and mental health problems (K-) Essen[al goods Debts Other goods food, water or electricity bills, rent house, car or K-: p<.5* clothes or leisure credit card debt K-: p>.5 K-: p>.5

30 Factors associated with mental disorders in 215 Types of financial deprivation Types of financial deprivation and mental health problems (MDE and GAD) % 5 MDE GAD Essen[al goods Debts Other goods food, water or electricity bills, rent MDE: p<.5* GAD: p<.5* house, car or credit card debt MDE: p>.5 GAD: p>.5 clothes or leisure MDE: p>.5 GAD: p>.5

31 Factors associated with mental health problems in 21 Perceived Social Position Median 28: 5th posi[on 215: 4th posi[on

32 Factors associated with mental health problems in 215 Perceived Social Position 25 Perceived Social Position and mental health problems (K-) Below median Equal or above median K-: p<.5*

33 Factors associated with mental disorders in 215 Perceived Social Position Perceived social position and mental health problems (MDE and GAD) MDE GAD 2 Below median Equal or above median MDE: p<.5* GAD: p>.5

34 Factors associated with mental health problems in 215 Social Support 2 18 Social support and mental health problems (K-) Low Bellow social median support Equal Good or above social support median K-: p<.5*

35 Factors associated with mental disorders in 215 Social Support Social support and mental health problems (MDE and GAD) MDE GAD 2 Low Bellow social support median Good Equal social or above support median MDE: p<.5* GAD: p>.5

36 Factors associated with mental health problems in 215 Community Involvement Community Involvment and mental health problems (K-) Low Bellow community median involvement Equal Good or community above median involvement K-: p>.5

37 Factors associated with mental disorders in 215 Community Involvement Community involvment and mental health problems (MDE and GAD) MDE GAD Bellow median Low community involvement Equal or above median Good community involvement MDE: p>.5 GAD: p<.5*

38 Factors associated with mental health problems (K-) in 215 Multivariate Analysis OR p-value Gender Men 1 Women Financial depriva;on 2.4 <.1 Self-rated health Self-rated mental health 6.34 <.1 Variables considered in the model: age; gender; educa[on; marital status; professional status; financial depriva[on; self-rated health; self-rated mental health; self-perceived socioeconomic status; social support; community involvement; financial depriva[on score

39 Factors associated with MDE in 215 Multivariate Analysis Gender Men 1 OR p-value Women 3.2 <.1 Educa;on 1 None or Primary 1 Basic Secondary.3.1 University Financial depriva;on 2.66 <.1 Self-rated mental health 7.56 <.1 Variables considered in the model: age; gender; educa[on; marital status; professional status; financial depriva[on; self-rated health; self-rated mental health; self-perceived socioeconomic status; social support; community involvement; financial depriva[on score

40 Factors associated with GAD in 215 Multivariate Analysis OR p-value Marital Status Married or cohabi[ng 1 Divorced, widow or separated,27 <.1 Single.7.46 Financial depriva;on 2.44 <.1 Self-rated mental health 6.71 <.1 Community involvement.44.3 Variables considered in the model: age; gender; educa[on; marital status; professional status; financial depriva[on; self-rated health; self-rated mental health; self-perceived socioeconomic status; social support; community involvement; financial depriva[on score

41 Factors associated with mental health problems in 215 Disability (Sheehan Disability Scale) 2 Disability and mental health problems (MDE and GAD) % MDE GAD 5 Work performance Social life Family life Overrall disability MDE: p<.5* GAD: p<.5 All analysis

42 Factors associated with mental health problems in 215 Disability (Sheehan Disability Scale) 3 Days out of role and productivity loss in the previous week 28 2 % MDE GAD 1 day out of role 1 loss of produc[vity MDE: p<.5* GAD: p<.5 All analysis

43 Services Utilization Characterization of services use Use of psychotropic medication Under-treatment Barriers to treatment

44 Services utilization Search for help due to mental health problems in the last 5 years Search for help due to mental health problems 18 Use of services for mental health problems Yes No Hospitaliza;ons Psychiatrist GP Psychologist

45 Services utilization Use of provider by type of mental health problem in the last 12 months Psychiatrist GP 15 Psychologist MDE GAD K- 25 K- <2

46 Services utilization Visits in the last 12 months (mean) Provider MDE GAD K->25 Psychiatrist 4,8 5,4 4,8 Psychologist,9 13,6 9,1 GP 2,9 3,2 3,1

47 Services utilization Use of psychotropic medication by group in 28 and Sleep medica[on An[depressives Tranquilizers An[psycho[cs

48 Services utilization Use of any psychotropic medication in 28 and

49 Services utilization Use of psychotropic medication by gender in 28 and Men Men 7.7 Women Women Sleep medica[on An[depressives Tranquilizers An[psycho[cs.9

50 Services utilization Under-treatment of people with major depressive episode (n=94)

51 Services utilization Under-treatment of people with generalized anxiety disorder (n=6)

52 Barriers Specific barriers LOW PERCEIVED NEED The problem went away by itself, and I did not really need help 41.3% 46.9% STRUCTURAL BARRIERS Financial I could not afford treatment 21.3% 36.5% I was concerned about how much money it would cost 2.1% 28.6% Service availability I was unsure about where to go or who to see 12.4% 17.7% Transporta[on I could not get an appointment 4.6%.7% I had problems with things like transporta[on, childcare, or scheduling that would have made it hard to get to treatment 4.2% 4.5% Inconvenient I thought it would take too much [me or be inconvenient 11.3% 5.6% Perceived ineffec[veness I didn't think treatment would work 11.1% 5.1% ATTITUDINAL BARRIERS S[gma I was not sa[sfied with available services 11.1% 4.7% I received treatment before and it did not work 5.9% 8.1% I was concerned about what others might think if they found out I was in treatment 5.7% 5.4% I was scared about being put into a hospital against my will 5.5% 3.9% Denial of help I wanted to handle the problem on my own 19.% 27.% I thought the problem would get be]er by itself 19.8% 22.7% The problem didn't bother me very much 5.8% 2.8%

53 Services utilization Barriers to treatment in 28 and Low perceived need Structural barriers Antudinal barriers

54 Services utilization Factors associated with visits to different providers in the last 12-month Psychiatrist /Psychologist OR p-value Educa;on None or Primary 1 Basic Secondary University Kessler- 1.1 <.1 Self-rated mental health 3.6.4

55 Services utilization Factors associated with visits to different providers in the last 12-month GP OR p-value Gender Men 1 Women Financial depriva;on.45.3 Self-rated mental health 6.12 <.1 Financial security.46 <.1

56 Conclusions There was a significant increase in the prevalence of mental health problems, specially in the group of more severe problems, from 28 to 215. The risk of having mental distress was particularly higher in women, the elderly, less educated people, individuals with higher perceived financial deprivation, unemployed and retired people, lower social support, and lower community involvement. Mental health problems are associated with higher levels of disability and days out of work. 27,9% of the individuals sought treatment for mental health problems in the last 5 years

57 Conclusions (Contin.) GPs were the most contacted professionals followed by psychiatrists and psychologists. Use of psychotropic drugs was higher in women and increased from 28 to 215. Low perceived need and structural barriers were the main obstacles for access to care and increased since 28. Despite the financial and staff cuts suffered since 28, overall, mental health services were able to respond to most of the pressure of the increasing needs of the population. Available data, however, revealed significant insufficiencies in terms of accessibility and quality of care.

58 NOVA Medical School Project Team JM Caldas de Almeida, Graça Cardoso, Manuela Silva, Ana Antunes, Diana Frasquilho, Daniel Neto, Benede]o Saraceno Partners Faculty of Social Sciences, University of Oslo Ins[tuto de Ciências Sociais, Universidade de Lisboa (João Ferrão) Universidade de Coimbra, CEGOT (Paula Santana & Adriana Loureiro) Universidade Católica, CESOP (Jorge Cerol) NOVA Informa[on Management School (Jorge Mendes & Helena Bap[sta) Escola Nacional de Saúde Pública, Universidade Nova de Lisboa (Julian Perelman) ARS Lisboa e Vale do Tejo (Luís Pisco) Lisbon Hospital Psychiatric Centre, CHPL (José Salgado) Hospital Magalhães Lemos (António Leuschner)

59 Interna;onal consultants Ron Kessler, Harvard Medical School, USA Jordi Alonso and Gemma Vilagut (IMIM, Barcelona) Kris[an Wahlbeck, Finnish Associa[on for Mental Health, Finland Arne Holt, Norwegian Ins[tute of Public Health NOVA Medical School Survey Team JM Caldas de Almeida, Miguel Xavier, Graça Cardoso, Manuel Gonçalves Pereira, Ricardo Gusmão, Joaquim Gago, Miguel Talina, Bernardo Corrêa, Joaquim Silva.

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