Depressive and anxiety disorders are the most common and disabling mental health problems in modern society. In the Netherlands, 7.6 and 12.4% of the adult population suffered from depressive or anxiety disorders in the last 12 months [4
], while in Australia these numbers were 6.6 and 5.6%, respectively [2
]. Despite the fact that effective treatments are available for depressive and anxiety disorders, the actual use of care for these common mental disorders is low and many people fail to receive treatment meeting minimal standards for adequacy, even in economically advantaged countries such as the Netherlands and Australia [2
To understand why service use is so low, more knowledge should be obtained about people’s perceived needs and barriers to receive care. The European Study of the Epidemiology of Mental Disorders (ESEMeD) has recently estimated the level of unmet need for mental health care. However, in this study, need was defined as having a 12-month mental disorder which was disabling or had led to use of health services in the year prior to the interview [1
]. In our view, diagnosis and need for treatment are not the same. Perceived
need and barriers to care, as measured from the patient’s perspective, have not been studied very often, except in Australia and the Netherlands [23
]. Some earlier studies examined the perceived barriers to care for mental health problems from a physician’s [15
], an adolescent’s [6
] or migrants’ point of view [11
]. One study about mental health services in Chile [33
] differentiated between direct (lack of available services, not knowing where to go for help) and indirect (belief that problem will solve on its own, negative beliefs about helpfulness of services) barriers to care. A Canadian study [40
] showed that perceived barriers due to acceptability were more prevalent than barriers due to accessibility and availability. A cross-national comparison study about reasons for not seeking care for a mental health problem in Canada, United States and the Netherlands [34
] concluded that the two most frequently endorsed reasons were “I wanted to solve the problem on my own” and “I thought that the problem would get better by itself”. Comparisons with newly derived data are difficult since, in these studies, no specific instrument was used to measure barriers to care.
Meadows and colleagues [25
] designed the Perceived Need for Care Questionnaire (PNCQ) for the Australian National Survey of Mental Health and Well-Being (NSMHWB), which is to our knowledge the first and only validated instrument that measures people’s perceptions of service needs for mental health problems and barriers to receive care. In 1997 and 2007, the Australian NSMHWB used this questionnaire in a population-wide sample. From 2004, it was also used in the Netherlands Study of Depression and Anxiety (NESDA), a longitudinal study about depressive and anxiety disorders [29
A cross-national comparison between Australia and the Netherlands could provide unique information on perceived care needs and barriers to mental health care, since this has never been measured by the same (validated) instrument in two different countries before. Combining these two data sets (NSMHWB and NESDA) will give us the opportunity to study a large sample of people with specific DSM-IV diagnoses. Specific characteristics of the health care system in Australia and the Netherlands might give explanations for possible differences and similarities between the two countries. In this study, the following research questions will be addressed:
- What perceived needs for care do people with a current anxiety or depressive disorder have in Australia and in the Netherlands, and what similarities and differences can be observed?
- If there is any perceived need for care, are people’s perceived need for care in Australia more often or less often fully met compared with people’s perceived need for care in the Netherlands?
- What barriers to care do people with perceived unmet or partially met need experience, and what similarities and differences can be observed between Australia and the Netherlands?
Comparing Australia and the Netherlands
The Netherlands and Australia are both high income group countries (based on World bank 2004 criteria) and show comparable numbers with respect to gross national income (GNI) per capita, life expectancy at birth, and health expenditure per capita [42
]. Both countries have formulated a mental health policy that includes advocacy, promotion, prevention, treatment and rehabilitation. The care provided is demand-driven and aiming to assure the rights of people with mental disorders [42
]. Mental health is part of the primary health care system in both countries, and general practitioners (GPs) provide the bulk of medical care; they are the first point of medical contact, and act as gatekeepers to the rest of the health care system.
Apart from these similarities, the two countries have health care systems that differ and could be divided into two broad categories. The Australian health care system has many similarities with a National Health Services (NHS) system, and the Dutch health care system mainly fits criteria for a Social Security (based) Health care (SSH) system. A NHS system is funded by means of general taxation and is strongly influenced by the state, while a SSH system is funded by means of earmarked premiums, has less state influence but strong influence from health care providers and (social) insurers [44
]. A complexity of the Australian system is that the State and Federally funded systems employ different funding models and the Federal route allows co-payment. Nevertheless, as in an NHS system, the influence of Government on entitlements is strong.
For many years, the Netherlands had a fragmented system of health insurance, with compulsory social health insurance for people with an income below a certain ceiling point, and a voluntary private health insurance section for people with a higher income [13
]. From the 1 January 2006, a single statutory insurance regime was introduced, which covers all residents of the Netherlands. All residents have a legal obligation to take out health insurance, for which they have to pay, and everybody has the option of taking out supplementary insurance [26
]. As a result of the reform, price competition between health insurers became very fierce, there was more transparency for consumers, and 20% of all consumers changed to another health insurer [13
]. As measured in 2005 and 2008, approximately 99% of Dutch citizens had taken out their (basic) health insurance, which covers GP care, primary care psychological care, and more specialized services (for which a referral from a GP is needed) [8
Though the Australian health system is built on the British model, it has evolved into something of a hybrid system. An Australian federal insurance provision is known as Medicare [22
]. Medicare provides tax funded health care insurance which covers much of the cost of care to the user. Most medical services are provided by private GPs and specialists on a fee for service basis that is indemnified by Medicare. However, the funded items have been predominantly medical ones. So, while GPs and psychiatrists have provided psychological treatments (which were covered), care from psychologists through this route was limited. Services funded through Australian states are free to the user—in mental health these typically have developed with continuity from psychiatric hospital establishments now with considerable community care activity, and a concentration on care of people with low prevalence disorders of high impact such as typically schizophrenia and bipolar disorder. Some funding for psychological services has been made progressively available with capped funding introduced for some services from 2002, and then more free availability of fee for service reimbursement since late 2006. Next to Medicare, Australia has also a significant private sector, with around 30% of the population having a private health insurance [22
While keeping this information about Australia and the Netherlands in mind, we aim to examine people’s perceived needs and barriers to care, and to identify similarities and differences in the two countries.