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and general medical care constituted the health care sector. The type of treatment received by individuals who reported use of a service in the health care sector was assessed. Pharmacological treatment was defined as that prescribed by a psychiatrist, general |
practitioner, or any other physician or health professional in the previous 12 months. Psychotherapy was defined as having more than one session in the past 12 months of psychological counseling or therapy with a mental health professional (psychiatrist or psychologist) |
that lasted 15 minutes or longer. Individuals who received neither drug nor psychological treatment were classified as being in the group with no active treatment. The definition of minimally adequate treatment followed previous research that was based on recommendations from |
clinical guidelines (15—17). It was defined as receipt of antidepressant pharmacotherapy for at least two months plus at least four visits with a psychiatrist, a general practitioner, or any other physician or health professional or at least eight sessions with |
a psychologist or a psychiatrist lasting an average of 15 minutes or longer. Human services and complementary-alternative medicine treatments were not considered to constitute adequate care because of the lack of experimental data documenting the effectiveness of such treatments for |
major depression (18—22). Chronic conditions and mental disorder variables The variable for chronic conditions included eight groups: musculoskeletal (arthritis), chronic pain (neck or back pain or other somatoform pain), digestive (stomach or intestinal ulcer), respiratory (asthma, allergies, or any other |
chronic lung disease), neurological problems, cancer, cardiovascular (stroke, heart attack, heart disease, or high blood pressure), and diabetes. The variable for mental disorders included mood disorders (major depressive episode or dysthymia), anxiety disorders (panic disorder, specific phobia or social phobia, |
generalized anxiety disorder, posttraumatic stress disorder, and agoraphobia without panic), and alcohol abuse or dependence. All analyses were performed with SASTM software, version 9.1, of the SAS System for Windows as well as SUDAAN, version 9.0, a statistical package used |
to estimate standard errors of data obtained from surveys with complex designs. Data analyses were carried out at the IMIM-Hospital del Mar in Barcelona, Spain, and at Harvard University in Boston. Lifetime prevalence of a major depressive episode in the |
overall sample was 10.6%, and 12-month prevalence was 4.0%. Table 1 presents data on sociodemographic characteristics of the total sample and of those with a lifetime and 12-month major depressive episode. Among respondents with a depressive disorder in the past |
12 months, 59.1% had used some type of service in the past 12 months for their emotional problems. As shown in Table 2, the highest proportion of service users (58.7%) reported use of services in the health care sector (either |
general medical care or specialized mental health). Among those who used services in the health care sector, the highest proportion reported use only in general medical care (35.3%). Among respondents who had used past-year services for emotional problems in the |
heath care sector, at least 76% received some type of active treatment: 70.1% reported receiving psychopharmacological treatment, either alone (37.9%) or combined with psychotherapy (32.2%). Receipt of no active treatment was highest among respondents with moderate major depressive episode (10.9%) |
and lowest among those with a mild disorder (5.0%). As shown in Table 3, among respondents who had received active treatment in the past 12 months from providers in the health care sector, 31.2% received treatment that met criteria for |
minimal adequacy. In the overall sample, meaningful differences were found by type of health service used: respondents who received both specialized mental health care and general medical care accounted for the highest proportion of those receiving minimally adequate care (38.6%), |
and the lowest proportion was among those who received services in general medical care only (12.8%). These differences were also found among respondents with severe major depressive episode. Results of logistic regression analyses of potential predictors of past-year service use |
among respondents with a 12-month major depressive episode are shown in Table 4. Respondents in the group aged 35—49 years were more likely than those in the other age groups to have used any services for their emotional problems within |
the past year (OR=5.7). Service use was also more likely among those in the "other" employment group (unemployed or too disabled to work) (OR=4.9), compared with those who were employed. Respondents who had a moderate disorder were more likely (OR=3.2) |
than those in the other severity groups to have used any services. Respondents who had more than one 12-month mental disorder (that is, a mental disorder comorbid with their depression) were significantly more likely than those with depression only to |
use any services (two mental disorders, OR=2.9; three or more mental disorders, OR=4.1). On the other hand, respondents with a low-average income were less likely than those with a high income to have used any services for their emotional problems |
in the past 12 months (OR=.3). The regression analyses also examined use of specialized mental health services in the past 12 months (Table 4). Respondents in the group aged 35—49 were more likely than those aged 18—34 to use these |
services (OR=3.0). Those with a severe or moderate disorder were significantly more likely to use these services than those with a mild disorder (OR=5.1 and OR=4.7, respectively). On the other hand, those with a high-average education level were less likely |
than those with a high level to use specialized services (OR=.3). The study found that 40.9% of respondents to ESEMeD-Spain with a 12-month major depressive episode reported not having used any type of service for their emotional problems in the |
past year. Moreover, 68.8% of those who received active treatment in the health care sector (specialized mental health or general medical care) did not receive minimally adequate treatment. Thus only 15.0% of all those with a 12-month major depressive episode |
had received appropriate care. Of particular concern is the 30.8% of those with a severe disorder who did not use any type of service for their emotional problems. By far, psychotropic medication was the treatment most used, either alone or |
(less frequently) in combination with psychological treatment. Higher odds of any service use were found among respondents with a moderate disorder, those with a comorbid mental disorder, those who were unemployed or too disabled to work, and middle-aged respondents. Study |
limitations and strengths Our results should be interpreted within the context of some limitations. First, information about treatment was self-reported, which could have led to recall bias. Previous studies have found that self-reports of service use for some mental disorders |
may be higher than use documented in administrative records (23,24). The WMH Survey tried to reduce recall bias by excluding respondents who failed to say that they would think carefully and answer honestly. Furthermore, use of a 12-month time frame |
can further reduce the risk of recall bias. Second, some analyses consisted of small numbers of respondents, and this might have affected the reliability of results. Third, ESEMeD excluded several population groups, such as those who were institutionalized or homeless. |
Although service use patterns of these groups may be different, their relative size is small, and it could be argued that overall population estimates would not diverge considerably if they were included. Fourth, there is no consensus on criteria for |
defining minimally adequate treatment; however, to our knowledge, the relationship between various criteria and significant clinical outcomes has not been studied. Fifth, the Spanish National Health System comprises 17 regional systems whose management relies on each regional government. As a |
consequence, the level of development of the mental health network, the allocation of economic resources, and the population density of professionals vary across regions; these differences may influence the use of services. Because of limitations in sample size, it was |
not possible to perform a more detailed analysis that would offer a clearer picture of probable regional differences. With these limitations in mind, we note that this is the first study that provides information about the use of services for |
a major depressive episode in Spain that is based on a nationally representative sample and that used a standardized methodology that allows for international comparisons. Previous research was restricted to specific regions and population subgroups (25,26) or clinical samples (27) |
or used mixed methodologies, which provided an incomplete picture of service use for depression. Our findings show that almost half of respondents with a major depressive episode did not use services in the health care sector for their emotional problems |
in the year before the interview. Although concrete and easily comparable data are lacking, some studies have found lower use of health services for mental disorders in certain southern European countries, such as Spain and Italy, compared with other European |
countries, but the rates are still higher than those found in many low-income American samples or in Asian countries (6,28). Comparable data on service use by individuals with major depression are even scarcer, but studies have shown that use is |
higher in Spain than in countries such as Italy and Germany (29) and lower than in some northern European countries, such as Finland, Ireland, and the United Kingdom (30). Although underrecognition and undertreatment of common mental disorders are frequent in |
most countries, substantive cross-national differences in treatment rates have been described. Treatment rates ranging from 50% to 79% in high-income countries have been reported, with rates typically lower in low-income regions (6). Reasons for these differences are not well known, |
but several factors have been proposed. They include factors that predispose patients to seek treatment, factors related to the type and amount of services available from the health care system, and factors related to health care professionals' ability to provide |
an adequate response to the need for treatment (6,31—35). The effect of social networks and support, which might be stronger in Spain than in other European countries (36), has also been discussed in the literature as either reducing service use |
by helping an individual to cope with stress or increasing service use by supporting treatment seeking (37). Although an extensive review of these factors is beyond the scope of this article, the relevant findings are summarized below. A personal level |
of comfort and confidence about consulting with professionals has been considered the most important factor in help seeking for depression, together with personal understanding and self-evaluation of the problem and the anticipated or experienced reactions of family and friends (31,32). |
Attitudes toward seeking mental health care seem to be more positive in Spain than in other European countries, and Spaniards seem to place greater trust in treatments provided by health care professionals (38). In regard to stigma, a well-known cultural |
barrier to help seeking for mental disorders (32), two recent studies showed that stigma may be less prevalent in Spain than in other European countries (39,40). Health system-related factors. The ability to access professional care is a key feature of |
health systems and also influences service use for mental disorders. Access to services is free and universal in the Spanish National Health System, as is the case in many other European countries, where treatment rates are, however, higher. A link |
between a country's overall spending on health care and the rate of treatment for mental disorders has also been described (6), and available data show that the amount spent in Spain is lower than the European average; this is also |
true of spending on mental health, which remains around 5% of Spain's total health care budget—one of the lowest spending rates in the European Union (41—43). The availability of services and of professionals is another relevant determinant that has also |
been linked to the use of services for depression. Studies have shown that regions with the lowest resources often have lower rates of consultation with health care professionals (44). Spain has fewer psychiatrists and psychologists and fewer available mental health |
services than many other countries with the same level of development, and differences are even greater for psychiatric nurses and social workers (9,42,43). Factors related to health care professionals. The Spanish National Health System is based on primary care, and |
referral from a general practitioner is usually required to gain access to specialized mental health services. Thus general practitioners act as gatekeepers of the system and have a key role in the correct detection and early management of most cases |
of depression. This is especially relevant in light of the high prevalence of major depression in primary care (45) and the evidence linking poor recognition of depression in primary care with worse short-term outcomes (46). In fact, underrecognition of depression |
in primary care has been extensively reported (47—49), and a recent meta-analysis that included more than 50,000 international patients showed that correct identification of depression by general practitioners occurred in only 47.3% of cases (50). This worrying situation has also |
been described in Spain (51,52), but international comparisons are scarce. Roles of general practitioners and mental health specialists Our results show that the proportion of respondents who sought service in the general medical care sector was only slightly higher than |
the proportion who visited mental health specialists. This finding is in contrast to other European countries and regions of the world, where general practitioners are clearly the professionals most frequently involved in the treatment of depression (6,44). This difference might |
be partly explained by the higher rates of referral to mental health specialists by general practitioners that have been described in Spain (44). These higher referral rates could be considered an attempt to improve the efficiency of a short-resourced health |
system. Additional factors, such as the relative delay in mental health care reform in Spain, may help explain why individuals with mild disorders were more likely to receive specialized mental health care. Sociodemographic and clinical correlates of use The likelihood |
of use of services for depression has been linked to a variety of sociodemographic factors, such as middle age, female gender, higher education and income level, and not being married (6,16,53,54). However, our results support only a few of them. |
Of special concern is our finding that women were no more likely than men to seek treatment. This finding should receive attention because the higher prevalence of depression among women compared with men in Spain was found to be much |
higher than in many other countries (5,55,56). Symptom severity is another major determinant of service use (30,57,58), and monotonic relationships between severity and the probability of service use have been previously described (6). Our results show that among individuals using |
any health sector services, those with a moderate disorder had higher odds of receiving treatment than individuals with mild disorders. Further research should be undertaken to confirm these findings—in particular, the role of severity and of gender in help seeking. |
Also, the finding that 31.7% of those with a severe disorder received care only from a general practitioner raises some concern about possible misallocations of scarce specialized resources, especially when the misallocations affect patients with higher risks of serious complications. |
Minimally adequate treatment In our study 31.2% of the patients with a major depressive episode who received active treatment from general medical or mental health specialty care received minimally adequate treatment, a rate considerably lower than in other European countries |
(17). Consistent with previous studies, our study found low overall rates of treatment adequacy (6,59) and more adequate treatment in specialized settings (16,60). Reasons for the low rate of treatment adequacy are unclear, but they presumably involve provider factors, such |
as inadequate training and failure to adhere to guidelines (16). Inadequate treatment has significant health and economic consequences, because treatments that meet clinical guidelines are more cost-effective and have been shown to decrease the number of years lived with a |
disability (61). Taken together the results offer a complex picture of patterns of service use for a major depressive episode in Spain. They include a less clear influence of disorder severity, a less relevant role for general practitioners than for |
mental health specialists, varying effects of sociodemographic factors, and a lower overall rate of minimally adequate treatment. Low rates of service use for major depression in a country such as Spain, with free and universal access to mental health care |
and a population with more positive attitudes toward help seeking for mental health problems, are worrisome and should call for a more proactive attitude of the health system. In particular, rates of comorbidity and of chronicity are higher in Spain |
than in other European countries (5), and both are a possible consequence of inadequate treatment and a possible cause of increased costs of major depression. Potential country-specific barriers to treatment, such as lower availability of services and of professionals and |
lower health care spending for mental health, may contribute to the low rates of service use. Although there are many budgetary constraints and competing priorities, reducing these barriers to treatment should be seriously considered to improve access to mental health |
care in Spain. Efforts should be made to enable general practitioners to better detect and manage depression, which may involve changes in their training and more effective development and dissemination of clinical guidelines. In addition, the fact that no gender |
differences were found in the likelihood of receiving treatment should stimulate specific actions aimed at increasing treatment rates among women as a high-risk population group. This is also true for the youngest cohorts, especially considering that the age at onset |
and SANCO-2004123 from the European Commission; the Piedmont Region of Italy; grant FIS 00/0028-02 from the Fondo de Investigación Sanitaria (FIS), Instituto de Salud Carlos III, Spain; grant SAF 2000-158-CE from the Ministerio de Ciencia y Tecnologáa, Spain; Departament de |
Salut, Generalitat de Catalunya, Spain; and by other local agencies and by an unrestricted educational grant from GlaxoSmithKline. ESEMeD is carried out in conjunction with the WHO WMH Survey Initiative. The authors thank the WMH staff for assistance with instrumentation, |
fieldwork, and data analysis. These activities were supported by grant R01MH070884 from the U.S. National Institute of Mental Health; the John D. and Catherine T. MacArthur Foundation; the Pfizer Foundation; grants R13-MH066849, R01-MH069864, and R01 DA016558 from the U.S. Public |
Health Service; grant FIRCA R03-TW006481 from the Fogarty International Center; the Pan American Health Organization; the Eli Lilly and Company Foundation; Ortho-McNeil Pharmaceuticals, Inc.; GlaxoSmithKline; Bristol-Myers Squibb; and Shire. The funding institutions had no further role in study design; in |
There were some notable differences between groups targeted for the 2009-10 pandemic and seasonal influenza vaccines, and substantial differences in target groups between countries. The greatest inconsistency in target groups was seen in comparisons between S0910 and P0910. Some groups targeted for the pandemic vaccine... |
health care workers were subsequently more commonly targeted for the 2010-11 post-pandemic seasonal vaccine. Subsidies to increase vaccine uptake were available to target groups in many countries by either providing the vaccine for free, at a subsidized cost or through national health insurance (Figures and ). Before f... |
(A) the social and political backgrounds of policy decisions to prioritize certain groups for P0910 are likely to differ from those for seasonal vaccines and (B) the 'best' or 'optimal' strategy to achieve certain public health objectives has yet to be fully clarified in the context of including or excluding certain gr... |
vaccines, public health decision of prioritized groups for P0910 may be more associated with maintaining social security during emergency vaccination and avoiding any confusion that could arise from 'first come, first served' basis among the public [8 ]. On the other hand, policymaking of seasonal vaccines is unlikely ... |
and to maintain social security, and rather, target groups of seasonal vaccines may sometimes reflect the results of surveys of public demands among the potential target groups and may also take into account aspects of cost-benefit and cost-effectiveness. With respect to (B), various studies including modeling exercise... |
clarification of all target groups. It should be emphasized that the limitations of modeling studies and inconsistency in target groups (as seen in the present study) may be attributable to non-uniform public health objectives of vaccination, such as reducing peak hospital burden versus reducing overall mortality, as w... |
against influenza viruses before and after vaccination. The objective of this study has been not to criticize certain choices of target groups, but to explore to what extent target groups are similar between countries, or even within countries from year to year and between the seasonal and pandemic vaccines. Some incon... |
targeting certain age groups, those with underlying medical conditions and those with occupations associated with higher risk. First, mathematical modeling studies have shown that achieving high vaccination coverage among school-age children could substantially elevate herd immunity and protect other risk groups (inclu... |
substantial attack rates in children before vaccines became available [21 ], and in such an instance (e.g. after observing epidemic peak), effectiveness of transmission-limiting strategy tends to be minimal [19 ]. While school-age children were targeted for the P0910 vaccine in some countries, most countries included i... |
groups for the P0910 vaccine (Figure and Table ). Second, with regard to underlying medical conditions, pregnant and postpartum women appeared to be at higher risk of severe disease if infected from the early stages of the pandemic [24 ] and many countries prioritized this group to receive the vaccine when it became av... |
targeted for seasonal influenza vaccination before the pandemic, evidence of an increased risk of severe influenza had already been observed in pregnant women before 2009 [28 ]. Influenced by the 2009 pandemic, 22/34 countries targeted this group for S1011 vaccine (Figures and , Table ). Other than pregnant women, a nu... |
a risk factor for hospitalization and death [26 ], and some countries incorporated obese individuals into the target groups for the P0910 vaccine and again retained them in the target groups for the post-pandemic S1011 vaccine (Figures and , Table ). Third, regarding roles and occupations, health care workers were targ... |
countries and they have been increasingly targeted during and after the course of the pandemic (Figures , and , Table ), although they may not necessarily face higher risk of infection due to occupational exposures [34 ] and the issue of mandatory vaccination in this group remains controversial [36 ]. Workers in long t... |
targeted for the pandemic vaccine compared to the seasonal vaccines, perhaps because of the apparent low risk of pH1N1 in the elderly [7 ]. Animal contacts might have been less commonly targeted merely because of displacement by other risk groups as P0910 vaccine was initially expected to be scarce. Later they were mor... |
which included the pandemic strain. A few limitations should be discussed. We were not able to find information on priority groups in many countries, and thus, the data included in our review may not sufficiently represent the worldwide patterns in target groups. In addition, information available online could differ f... |
included in our study was from official government websites. Potentially lower quality sources were excluded by limiting our search to official webpage of the government, news or academic journal articles. Future studies of influenza vaccine policies could consider a survey-based approach interviewing a representative ... |
relation to the policy decisions of target groups when relevant data are available as part of policy evaluations. There were also within country variations; e.g. recommendations on target groups in Canada and the United States differed between states. In these situations, the federal recommendations were used to reflec... |
Michael Dirda: "Five Propositions About Poetry" - In a very general sense, poets tend to use language in two ways: the artful or the natural. Either they transmute their thoughts through metaphor, striking imagery, or unusual syntax into something rich |
and strange; or they pack their meaning into what Wordsworth famously called the language really used by men (and women). On the one hand, Wallace Stevens, Gerard Manley Hopkins, and Jorie Graham; on the other, William Carlos Williams, Archilochos, and |
Billy Collins. Most poets opt for flash and filigree—after all, "O, for a beaker full of the warm South, / Full of the true, the blushful Hippocrene" (Keats) sounds like poetry. It takes real confidence, and sure judgment, to set |
down words as simple and deeply moving as "Pray, undo this button" (Shakespeare). - Where a "Complete Poems" is a monument, a "Selected Poems" is an invitation, a sometimes needed icebreaker for shy new readers. In other words, most of |
us. Just as expository prose generally aims to ingratiate, emphasizing clarity and communication, so a lot of poetry blithely ignores the ordinary courtesies: It is simply there, true to itself. Let me be fanciful: If you picture good prose as |
a smooth politician deftly reaching out to the crowd and welcoming everyone into the party, then poetry is Clint Eastwood, serape flapping in the wind, standing quietly alone on a dusty street, pure coiled energy. He's not glad-handling anybody. - |
To read a volume of poetry is to enter the world of the mesmerist. In a serious artist's collected poems, the single constant is usually his or her distinctive, increasingly hypnotic voice. Without relying on plot, dramatic action, or a |
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