healthmedicinet

We investigated demographic, socioeconomic, and health-related, and health-condition
factors associated with the underutilization of professional mental health services
for potential depression symptoms. Among those who reported depression symptoms during
the past year, we observed that 17.4 % had received professional mental health consultation
for the depression symptoms. Young adults showed the lowest prevalence of professional
mental health service use, but after adjustment of demographic, socioeconomic, and
health-related factors, we observed the higher rate of service use, which is inconsistent
with a previous study showing more negative attitudes in young and middle-aged adults
7].

A previous study found that elderly individuals with depression were less likely to
contact mental health professionals than middle-aged individuals were 7], which is consistent with our findings. Although protective factors—such as high
self-reliance—in older adults could be linked to underutilization of mental health
services 7], 23], elderly individuals with potential depression symptoms are more likely to have co-existing
chronic illnesses, such as cardiovascular disease 24], 25], or functional disability 26]. In addition, prior to committing suicide, elderly individuals tend to contact primary
care providers rather than psychiatrists 27]. Collectively, these findings highlight the role of primary care providers in the
management of mental health of elderly individuals 28], 29].

The present study showed that men contacted mental health professionals for potential
depression symptoms less frequently than women did, which is consistent with previous
findings on mental health service use 7], 30]. This may be related to gender differences in help-seeking behaviours 31]. Specifically, men may perceive greater stigma, while women may more easily acknowledge
and recognize mental illnesses from nonspecific distressful emotions 32], 33]. Contrastingly, because women tend to internalise their feelings 34], they may have more severe symptoms, which is consistent with the significantly larger
proportion of women with high perceived stress in our study.

Although low socioeconomic status may increase the risk for depression and suicidal
ideation/behaviours 35]–37], the present study showed no significant difference in the rates of seeking formal
mental healthcare for potential depression symptoms across income quartiles. This
may be attributable to the National Health Insurance system adopted in the Republic
of Korea, which may have helped reduce the socioeconomic gap in medical care utilization
38]. However, after stratification by age, young adults with the lowest income level
showed higher rates for mental health service use compared to all other income groups,
while elderly individuals with the lowest income level had lower consultation rates
compared to the highest income level. The effect modification of age may indicate
that elderly individuals’ use of mental health services depends more on income than
it does for other age groups. In the Republic of Korea, elderly individuals’ suicidal
behaviours are most likely motivated by financial problems 39]. Further, the income poverty rates late 2000s for elderly Koreans was 45.6 %, which
is four times higher than the average among OECD countries 40]. Although elderly people with financial problems may be exposed to greater psychosocial
distress, they were less likely to seek professional help for potential depression
symptoms. Further, elderly individuals with a lower income may be socially isolated
and may have difficulties engaging in help-seeking behaviours, even though they show
positive help-seeking attitudes for mental health problems. Thus, it is imperative
that target strategies for elderly individuals’ mental health are established at the
community level, such as strengthening social networks.

Although unemployment is associated with suicide 41], 42], the present study suggests that employed individuals were less likely to use professional
mental health services than unemployed individuals were. One explanation is the stigma
surrounding depressive disorders 43]. In this regard, the Korean government plans to revise the Mental Health Act such
that patients with mild symptoms—requiring only outpatient care—will be excluded from
the definition of a ‘psychiatric patient’ 44]. However, this change may not address the psychosocial aspects of stigma; interventions
that strengthen social supports and discourage discrimination against individuals
with mental illnesses need to be enforced. Nonetheless, our findings should be interpreted
with caution because we did not consider time-dependent employment status. Those who
were unemployed at the time of survey completion may have been previously employed
and may have lost their jobs as a result of severe depressive symptoms. In this regard,
programs in the workplace for employees’ mental health can help prevent the aggravation
of depression symptoms.

Patients with diabetes mellitus were significantly less likely to seek consultation
for potential depression symptoms, whereas those with other chronic diseases, such
as hypertension, had high consultation rates. Diabetes increases the risk for psychosocial
problems, which may have an adverse effect on diabetic patients’ self-care practices
45]. A previous study reported that approximately 10 % of patients with diabetes and
psychosocial problems received professional help for their psychosocial problems 45]. One explanation for the discrepancy between diabetes and other chronic diseases
is that patients with diabetes and psychosocial problems are less likely to engage
in effective diabetes management because of the less noticeable symptoms even with
poor management (e.g. pain or dyspnea in patients with mild diabetes). However, we
were unable to classify participants according to the severity of diabetes mellitus
in the present study. Further investigation of the link between diabetes, psychological
problems, and mental health service utilization needs to be conducted.

Strengths and limitations

In this study, we used a large and nationally representative sample to investigate
the factors associated with utilization rates of professional mental health consultation
for potential depression symptoms. However, several limitations should be considered.
Healthy individuals were included among those asked to complete the CHS questionnaires.
Thus, the survey did not exclusively focus on those with severe mental problems or
suicidal completion. However, given that the present study intended to explore factors
associated with underutilization of mental health services, the exclusion of severe
cases from this study might not have distorted our results. The participants were
selected based on a single self-reported item on depressive symptoms, rather than
assessments using psychometric instruments. However, this question is used to determine
an essential criterion for major depressive disorder as per the Diagnostic and Statistical
Manual of Mental Disorders, 4
^th
Edition. Thus, regardless of diagnostic criteria for specific disorders, we were able
to identify individuals with depressive symptoms who deserve further evaluation by
mental health professionals. Moreover, even though participants who reported having
consulted a mental health professional may not have met the criteria for depressive
disorders, this does not diminish the present findings since our focus was on patients
who required mental health consultation rather than those who met the criteria for
depressive disorders. Furthermore, we used a cross-sectional design, which precludes
any inferences regarding causation (i.e. the possibility of reverse causality remains).
Thus, any interpretation of time-dependent variables (i.e. marital, employment, smoking,
and drinking status) should be considered with caution; future studies utilizing a
prospective design are needed.