37 Income inequalities beyond access to mental health care Figure 1. Income gradients in severity at baseline assessment, treatment minutes, functional improvement and additional treatment record by diagnosis DISCUSSION Our results show that income inequalities exist across different stages of specialist mental health care. Patients in the lowest income quintile were more than twice as likely to use specialist mental health care compared with those in the highest income quintile and had greater disease severity at baseline. We also found that when adjusted for need, the amount of treatment provided was slightly lower for patients in the lowest income quintile. Functional improvement was positively associated with income, displaying a substantial gradient that is not explained by different or concurrent diagnoses, lower severity at baseline, higher treatment minutes, or different type of therapies. By the end of the initial treatment record, patients in lower income quintiles were more likely to receive additional treatment in a subsequent record, but the difference compared with individuals in higher income quintiles was small. Despite differences in how various disorders are treated, there was little heterogeneity in gradients across diagnoses. This finding suggests that income disparities were not driven by disorder-specific mechanisms but are common features of the mental health care process in the Netherlands. Our study contributes to the literature by showing that income gradients in access to mental health care persist throughout the different stages of treatment, and that there are 2
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