10 Chapter 1 to care shows that the magnitude and direction of the inequalities vary depending on the socioeconomic measure used (e.g. education, income), the type of care studied (e.g. specialist vs. non-specialist, but also psychiatrists vs. psychologists), and across countries with different levels of coverage and publicly funded services. Studies from high-income countries as the Netherlands, Denmark, Australia and Canada suggest that low-income individuals are more likely to access mental health support provided by human services such as social workers or counsellors in non-speciality settings, general practitioners or public-funded psychiatric services [29-33]. At the same time, studies report higher income individuals as more likely to access care from psychologists both in settings with (Canada and Denmark) and without (Germany) out-of-pocket payments for these services [29, 31, 34]. High-income individuals were also more likely to access psychiatric care in countries with limited health care coverage, like the United States of America [32]. Another relevant and related stream of literature is the one that reports cost-sharing as a financial barrier to access care, even in the most egalitarian countries such as the Netherlands [35-37]. Besides income, education also strongly influences access to mental health care. Evidence from the Netherlands and Canada consistently displayed highly educated individuals accessing psychiatric and psychologist services more often than low-educated ones [38, 39]. While inequalities in access to mental health care remain a challenge in most counties, efforts to promote equitable access to treatment have lately gained space within policy agendas. Much less attention is paid to what happens once individuals start treatment, and the potential “quality gap”. The few studies that examined individual-level disparities in the amount of treatment received suggest that, conditional on accessing to care, low socioeconomic status is associated with a reduced rate of visits [31, 40]. Literature is even more scarce in what concerns inequalities in outcomes. Existing observational studies are small and present mixed findings on the associations between area-based measures of deprivation and treatment outcomes [41, 42]. More robust evidence is only available from experimental settings, with differences by socioeconomic status being observed in randomised clinical trials (RCTs) and their follow-up data. These studies have shown that both pharmacotherapy and psychotherapy approaches had higher magnitude effects for individuals with depression who had higher education and income or those who were employed and homeowners [43, 44]. Importantly, inequalities identified in RCTs settings are likely to be even larger in the real world, where treatment adherence and continuation are lower, and influences of doctor/patient preferences and beliefs are not accounted for through randomisation. Describing disparities in mental care delivery and outcomes is, therefore, a priority to inform policy-makers on closing the mental health gap. The lack of evidence might be partially caused by the challenge of simultaneously observing the need for and the utilisation of mental health services and socioeconomic status. Appropriately assessing patient need is essential in the context of the horizontal equity principle equal treatment
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