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Articles   |    
Inequalities in the Use of Services Provided by Psychiatrists in Spain: A Multilevel Study
Kátia B. Rocha, Ph.D.; Katherine Pérez, Ph.D.; Maica Rodríguez-Sanz; Jordi Alonso, M.D., Ph.D.; Carles Muntaner, M.D., Ph.D.; Carme Borrell, M.D., Ph.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201100419
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Dr. Rocha is with the Department of Psychology, Pontifícia Universidade Católica do Rio Grande do Sul, Avenida Ipiranga 6681, Porto Alegre, Rio Grande do Sul, Brazil (e-mail: katia.rocha@pucrs.br). Dr. Rocha is also with the Health Information Systems Service, Agència de Salut Pública de Barcelona, where Dr. Pérez, Ms. Rodríguez-Sanz, and Dr. Borrell are affiliated. Dr. Pérez, Ms. Rodríguez-Sanz, and Dr. Borrell are also with CIBER Epidemiología y Salud Pública, Madrid, Spain, where Dr. Alonso is affiliated. Dr. Alonso is also with Institut Hospital del Mar d’Investigacions Mèdiques, Barcelona, Spain. Dr. Muntaner is with the Bloomberg Faculty of Nursing and the Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  The objective was to identify individual or contextual inequalities in visits to psychiatrists in Spain, a country with a regionalized health care system and variable integration of mental health and primary care.

Methods  This cross-sectional study used data for the noninstitutionalized population from the 2006 Spanish Health Interview Survey (N=29,478). A score of ≥3 on the General Health Questionnaire represented a need for mental health care. The probability of having visited a psychiatrist in the previous four weeks was analyzed in relation to individual-level variables (age, social class, health insurance, and country of origin) and contextual socioeconomic variables (Gross Domestic Product; a measure of income equality; and characteristics of regional mental health systems, such as human resources, services, and organization). Multilevel logistic regression models were used.

Results  A total of 161 individuals (.55% of the sample) reported a visit to a psychiatrist during the previous four weeks. Individuals age 65 and older and immigrants from low-income countries were less likely to report a visit. Visits to psychiatrists were more common in regions with higher rates of psychiatrists per hospital (odds ratio [OR]=1.47, 95% confidence interval [CI]=1.18–1.83), more human resources for mental health (OR=1.03, CI=1.01–1.06), and better integration of primary care and specialized mental health care (OR=1.90, CI=1.32–2.76).

Conclusions  Individual and contextual inequalities in use of psychiatrists’ services exist in Spain. Better coordination between primary and mental health care and greater availability of mental health resources were associated with greater use. Policies seeking better integration of care should be promoted.

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Table 1Characteristics of 29,478 respondents to the 2006 Spanish Health Interview Survey who reported having visited a psychiatrist in the month before the interview
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a 12-item General Health Questionnaire. A positive score (≥3 points) indicated the presence of psychological distress.

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Table 2Distribution of contextual variables across 17 Autonomous Communities in Spain
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a Spain index=100

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b A measure of income equality, where 0=perfect equality and 100=perfect inequality

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c Psychiatrists, psychologists, and psychiatric nurses

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Table 3Regression models of predictors of a reported psychiatric visit among respondents to the 2006 Spanish Health Interview Surveya
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a Model 1: τ2=.13042, p=.005; model 3: τ2=.00005, p=.04. Proportional change in variance for models 1 and 3=99%

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b 12-item General Health Questionnaire. A score of ≥3 points (positive score) was taken to indicate the presence of psychological distress.

Table Footer Note

c A measure of income equality

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d Psychiatrists, psychologists, and psychiatric nurses

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