27 Income inequalities beyond access to mental health care Although obtaining access to appropriate care is a prerequisite to reduce mental health inequalities, it is probably insufficient. Some evidence based on randomised controlled trials showed differences in treatment effectiveness by socioeconomic status. A meta- analysis combining individual patient data found that improvement after any treatment was positively associated with employment and home ownership [20]. Notably, associations of improvement with financial strain and lower education disappeared when controlling for clinical prognosis factors [20]. Relatedly, data from randomised controlled trials of several pharmacotherapies and psychotherapies for depression showed stronger positive effects among individuals with higher education and income [21, 22]. These findings from experimental settings highlight the need for population-level evidence on inequalities beyond access to care, and particularly on disparities in mental health outcomes. In this study, we aimed to examine income inequalities in four stages of mental health treatment, using nationwide data for all first specialist treatment records in the Netherlands. METHODS Study design We performed a retrospective cohort study examining adults living in the Netherlands who started specialist mental health treatment between 2011 and 2016. In the Netherlands, specialist mental health care typically follows a referral from a primary care physician to a specialist care institution where the main practitioner is responsible for defining a patient’s primary diagnosis and completing the treatment record. The treatment is tailored to each patient’s case and could include care provided by clinical psychologists, psychiatrists, or multidisciplinary teams. Specialist mental health care is covered by a standard benefit package in a setting of mandated universal health insurance. Patients with low income receive government subsidies to reduce the premium costs paid to health insurers. Health insurers pay care providers on the basis of treatment records, which contain standardised information on the services provided. A single treatment record consists of all the care received for up to 1 year after its opening. Treatment continuation after 364 days or starting treatment with a different provider or diagnosis requires a new record. If applicable, a proportion of the provider cost paid by the insurer is billed to the patient as a deductible: in each year patients pay out-of-pocket for any health care received, excluding primary care but including mental health services, until they reach the deductible threshold. The total annual compulsory deductible ranged from €170 (US$237) in 2011 to €385 (US$426) in 2016 [23]. Other out-of-pocket payments and respective changes throughout the study period are described in the Appendix A. 2
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