Americans who suffer from major depression get the treatment and medication management they need less than half as often as do their Canadian counterparts.
Steven J. Katz, MD, of the University of Michigan, and colleagues studied the results of mental health surveys of 574 Americans and 250 residents of Ontario, Canada, aged 21 to 54, all of whom met the criteria for major depression.
Writing in the February 1998 issue of the Journal of General Internal Medicine, they report that only a small fraction received appropriate care in either country - 15 percent of the depressed Canadians and 7 percent of the depressed Americans surveyed. They define "appropriate medication management" as a combination of self-reported antidepressant medication use and four or more visits to a health care provider within the previous 12 months - the approximate guidelines of the Agency for Health Care Policy and Research.
This between-country difference in care was the result of more Canadians than Americans receiving any care for depression: 55 percent of depressed persons in Ontario received mental health services from either general practitioners or mental health specialists, compared to only 30 percent of Americans.
The researchers attribute much of the difference between the two countries to economic barriers, noting that Canada's national health plan provides comprehensive mental health coverage. In Ontario, there are no limits on either outpatient visits or inpatient stays for psychiatric care, and only minimal co-payments are required for ambulatory services.
In the survey, more Americans said mental health services were too expensive (about 32 percent compared to 8 percent in Ontario) or they were unsure where to go for them (33 percent compared to 15 percent).
But patient attitudes also contribute. In both countries "approximately 40 percent of depressed persons who did not make contact (with a physician) did not perceive the need for professional help," the authors write, and "more than half of those who did perceive need for professional help did not seek it because they felt that they would get better on their own or that professional help would do no good."
The authors say their findings support contentions that "reducing financial barriers to mental health care can improve quality," but that even in Ontario the prevalence of appropriate care remains too low.
"The low rate of contact due to knowledge and attitudinal barriers supports the importance of efforts to educate the public...about depression and its treatments.... Our findings (also) clearly reinforce the notion that the treatment of depression represents a missed opportunity for clinicians in both countries....
"Thus, clinical guidelines that educate providers, especially general physicians, about the recognition and treatment of depression may improve quality. This strategy may be particularly useful in Ontario, where there is relatively greater reliance on general practitioners to manage the treatment of depression."
The research was supported by the Robert Wood Johnson Foundation and the National Institute of Mental Health.