There is low use of service among ESEMeD countries

Although mental disorders are frequent in the ESEMeD countries, the rate of people who consult a medical professional for their mental health problems is considerably low. Among those with a 12 – month mood disorder, only between 36% (in Italy) and 56% (in the Netherlands) reported having consulted a general medical professional due to problems with emotions or mental health.

Among users of services, general medical professionals were the most frequently consulted in all countries (66 % on average), while the use of a mental health specialist ranged from 39.4% in France to 52.2% in Spain (EPREMeD).

See also the probability of visiting a health care professional during the first year after the onset of major depression in 6 EU countries

Recognition of depression in primary care is low

Although the primary care setting is considered important for depression prevention and treatment of depression, it has shown little recognition of depression and has not always offered adequate treatment (Ormel et al., 1991; Wittchen et al., 2001b; Van Os et al., 2006). There may be several reasons for this:

• The presentation of depression may be more difficult in primary care because of a high proportion of mild depressive episodes. Wittchen et al however, found in 2002 that the vast majority of depression seen by primary care physicians is of a moderate or severe nature according to the criteria of the ICD-10.
• There is a lack of diagnostic and treatment skills among general practitioners.
• In primary care, physicians typically have little time per patient (Wittchen & Pittrow, 2002).
• Patients in primary care might be more reluctant to accept the diagnosis of a mental disorder.

Physicians are more likely to identify depression when:

• The disease is more severe.
• The patient experiences less somatic comorbidity and somatic symptoms (Tiemens et al., 1996).

The under- and inadequate treatment of depression in primary care is the reason that many community-based depression and suicide intervention programs target primary care physicians.

Undertreatment of depression throughout Europe

The ESEMeD Study revealed that only 45% of depressed persons in need appear to be treated adequately. Adequate treatment was defined in this context as over the period of two months:

• Either receiving antidepressant medication plus minimum four visits to a physician
• Or at least eight sessions with a psychologist or psychiatrist of at least 30 minutes duration.

The likelihood of depressed persons receiving adequate treatment was substantially higher in specialised care (57%) than in primary care (23%). In northern countries (Belgium, France, Germany, and the Netherlands) treatment adequacy was higher in the specialised sector, whereas no difference was found in southern countries. Reasons for these variances between countries might be related to:

• Different health care systems. Spain and Italy have a national health service financed by taxation, whereas the other systems are financed by compulsory social health insurance (Fernández et al., 2007).
• In countries such as Spain and Italy there is a need for referral to specialised mental health care (Fernández et al., 2007).
• The availability of treatment guidelines in France, Germany and the Netherlands (Fernández et al., 2007).
• Another explanation could be the availability of psychiatrists and psychologists. The Netherlands, France and Germany have more psychiatrists and psychologists per 100,000 people (resp. 37, 27 and 62) in comparison to Italy and Spain (resp. 13 and 6) (WHO, 2007).