26 Chapter 2 INTRODUCTION Even though the need for mental health treatment is often concentrated among individuals with low incomes [1-5], people with higher incomes generally use specialist mental health care more, often because financial barriers prevent low-income people from accessing such care [6-9]. Advocates of mental health care reform worldwide have looked to the Netherlands, which has universal and comprehensive mental health care coverage and lower out-of-pocket costs, as a model of ensuring access to adequate mental health treatment for all [10-12]. However, no previous work has evaluated whether the mental health outcomes of such a system are equitable across the income distribution. The current literature shows that there is low and unequal access to mental health care. However, the direction of the disparities varies across countries, measures of socioeconomic status, and types of services [6-9, 13]. Studies conducted in Australia, Canada, Denmark, and the Netherlands found that low-income people access mental health treatment more often than higher income groups through social or primary healthcare workers. In contrast, access to psychologist services was more frequent in those with a high income, both when copayments applied [7] and when financial barriers were low. [8, 14] Access to psychiatric care does, however, depend on coverage. Comprehensive coverage, in countries such as Denmark, was associated with a higher use of specialist care by low-income individuals than in other countries [7], but in countries with low coverage, such as the USA, care was concentrated among high-income individuals [9]. When using education as a measure of socioeconomic status, studies consistently reported individuals with higher educational attainment to have greater access to most types of care than individuals with lower educational levels [15, 16]. Similarly, a multicountry study revealed a modest positive association between education and access to specialist care, but a non- monotonic association between income and treatment rates, with lower specialist treatment rates for middle-income respondents compared with both high- income and low-income respondents [17]. Most of the current literature is focused on access to mental health treatment and there is less evidence available on inequalities among patients in mental health care. This absence of evidence is because of the difficulty in disentangling need for and the use of mental health care across the income distribution during different treatment stages. Most existing studies were limited in the outcomes they observed, such as access or number of visits, relied on samples not larger than several thousands of patients, or could only control for crude measures of need. The few studies that evaluated the amount of care received concluded that individuals of a high socioeconomic status had a higher rate of contact with services [7, 18]. In a cross-country comparison, only a few individuals received minimally adequate treatment overall, with a considerable gradient in favour of high- income countries [19].
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