228 Summary Chapter 5 focused on the choice of treatment for depression by General Practitioners (GPs), exploring the lack of psychological therapy availability as a determinant of antidepressant prescription. We investigated the relationship between psychotherapy supply and GPs antidepressant prescription in Portugal, a country with one of the highest antidepressants consumption and a very low number of psychologists working in primary care, where they are hired by local groups of GP practices. Using panel data on all GPs in Portugal between 2015 and 2018 we found heterogeneous effects of increasing the numbers of psychologists in the within-GP share of antidepressants prescribed to patients with depression. For the subgroups of GPs exposed to the lowest and highest average levels of psychologists during the study, increasing one psychologist/100,000 patients led to a reduction in GP antidepressant prescription overtime. Additionally, the use of a within-between random effects model allowed us to study the association of prescription patterns with the between-GP variation in the average number of psychologists hired by each local group. These findings showed that GPs working in local groups with one-unit higher number of psychologists/100,000 patients, on average during the study, had a lower prescription share. When comparing the within- and between-GP estimates, the larger magnitude of the latter might be explained by unmeasured characteristics and processes that lead GPs prescribing antidepressants less to work in settings with higher supply of psychological therapy. Policy aimed at reducing antidepressant prescription should examine these processes further, while considering that small increases psychologists availability might not lead to a reduction of prescription across all levels of supply, at least in contexts of scarce psychotherapy resources as the Portuguese primary care. In conclusion, ensuring appropriate levels of support to patients with mental health needs is complex and spans different types of health and social care services. Policymaking should recognize this complexity and that increasing 1) availability, 2) eligibility, 3) coverage are not necessarily a solution to 1) balance the provision of drug and psychological treatment as treatment approaches 2) achieve the appropriate level of community support for best integration in the society and 3) reduce inequalities in mental health treatment and outcomes. Financial barriers continue to be a challenge in promoting access to mental health treatment by vulnerable groups, although access to care by itself is no solution to reduce inequalities, which persist during the treatment pathway. More causal evidence on the distributional effects of interventions is needed to inform decision-making on the topic of mental health inequalities, which has ultimately been gaining space in policy agendas. As described in chapter 6, quasi-experiments have substantial potential to contribute to this gap. This potential should be maximised through interdisciplinary research, and through the joint effort of research and policy to shape the conditions in which quasi-experimental evaluations can achieve their highest societal impact.
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