226 Summary SUMMARY Mental disorders pose an extremely high burden to society, both in terms of their direct effects on health but also societal welfare losses. This burden is distributed unequally and strongly impacts groups of low socioeconomic status (SES). Also unequal is the access and utilization of mental health services, which should be concentrated among those who most need treatment. While the actual magnitude of inequalities in access to mental health care is difficult to quantify due to challenges in measuring need at the population level, evidence suggests that the treatment gap is the largest for those in socioeconomic disadvantage. Much less is known about what happens beyond access to care, as inequalities along the mental health treatment pathway have rarely been described in the literature. Evidence about policy effects on mental health inequalities is also scarce. Identifying the interventions and programs that work for the most vulnerable groups is a priority to inform policy on reducing mental health inequalities. Furthermore, it remains crucial to understand what policies might be unintendedly widening the mental health gap. In the context of these knowledge gaps the objectives of this thesis consisted of 1) characterising disparities in the provision of care to people with mental health conditions and 2) identifying causal effects of mental health related interventions, programs and policies with impact on the most vulnerable patient groups, using quasiexperimental methods. To contribute to the first objective, we have examined treatment inequalities by income for those with access to specialist mental health care, between 2011 and 2016. Chapter 2 examined four stages of the treatment pathway: severity at baseline assessment based on the Global Assessment of Functioning (GAF) score, treatment minutes, functional improvement by the end of the initial record, and additional treatment in a subsequent record. Estimates were adjusted for patient need (97 categories of primary diagnosis and severity at baseline assessment measured by GAF) and demographic covariates. Based on a nationwide cohort of adult patients with a first treatment record we found that those with the lowest income had the greatest baseline disease severity, but they received slightly fewer treatment minutes than the rest. In terms of treatment outcomes, those with higher income were substantially more likely to have functional improvements by the end of the initial record. They were less likely to have an additional treatment record than those in lower income quintile, but only by a small difference. These disparities were not explained by differences in diagnosis, severity at baseline, or treatment minutes received. Our results are pivotal in quantifying disparities favourable to patients with a higher income that persist through the different stages of mental health treatment. While calling for a better understanding of the role of social environment and quality of care as complementary mechanisms, these findings highlight the limitations of solely focusing on access to care to reduce the mental health gap.
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