201 General Discussion Chapter 3 evaluated the effects of substantially increasing patient cost-sharing in access to mental health care during the transition to adulthood. It explored youngsters’ first obligation to pay for part of their treatment through a deductible at 18 years old. Our findings from this quasi-experiment show that a 180 euro increase in the deductible between 2011 and 2013 led to lower use of mental health care by females, decreasing their likelihood of continuing or starting specialist mental health treatment at 18. These findings were driven by effects in young women from households with income below the population’s median. Such differential effects highlight how financial barriers widen inequalities in mental health care by impacting those with lower incomes. We have further explored the effects of increased deductibles on youngsters who were in treatment at the age of 17. We investigated whether there were differences in treatment cessation at 18 by the intensity of their previous treatment or the medicines they used for mental health disorders. We found that young adults receiving low and medium-intensity treatment and males using ADHD therapeutic agents would stop treatment the most in the high deductible period. Still, a sizeable higher discontinuation was observed across the entire spectrum of mental health needs. This finding raises concerns that a disruption of treatment due to the increased deductible could result in relapse or recurrence and subsequent functional disability of some patients, with potential long-term consequences on their health and development. Our findings could disentangle the role of cost-sharing - in the form of increased deductibles – from other discontinuous changes occurring at 18 that could impact care use (for example, moving living location). They are, therefore, seminal in showing that increased cost-sharing compounds to poor transitional mental health care into adulthood. In past research of transitional psychiatry, financial barriers have often been disregarded in favour of other service- or individual-level factors [10, 11]. Our findings should caution against using blunt deductibles in developmentally-sensitive phases of the life-course. About ¾ of mental disorders have their onset during adolescence and young adulthood, and they are also the main cause of disability in adolescents of high income countries. Barriers to treatment are only likely to intensify the effects of poor mental health in youth, and increase their persistency into adulthood. Our findings within the Dutch system are relevant to countries with changes in financial arrangements tied to adulthood or with cost-sharing for mental health treatment. Together with the conclusions of previous studies on other populations and types of care, our results highlight the risk of increasing disparities due to cost-sharing mechanisms that are blunt to individuals´ income and health needs [12-15]. The disproportional effect of cost-sharing on youth mental health care use, identified in a country with universal health care coverage and relatively low out-of-pocket expenditure, might be even more significant elsewhere. In the Netherlands, supported housing is a key alternative for patients with mental health conditions to live in the community, particularly those in vulnerable psychosocial and socioeconomic circumstances. It offers a comprehensive package that includes housing, 7
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