Are Mental Health Care Needs Met Equally for Adolescents from Different Socioeconomic Backgrounds in Sweden?

What you need to know

• Adolescents from lower socioeconomic backgrounds were more likely to have mental health problems but also more likely to use mental health care services overall.
• Use of mental health care for ADHD/autism spectrum disorders appeared to be equitable across socioeconomic groups.
• There were indications of unequal mental health care use for other disorders like depression and anxiety, particularly among girls from lower socioeconomic backgrounds with moderate to severe symptoms.
• Further research is needed to understand and address potential barriers to mental health care access and use for adolescent girls from disadvantaged backgrounds.

Background and Purpose of the Study

Mental health problems often emerge during adolescence, with an estimated 14-31% of adolescents globally experiencing at least one mental disorder. Previous research has shown that adolescents from families with lower socioeconomic position (SEP) are more likely to have mental health issues compared to their peers from higher SEP families.

Given this social gradient in mental disorders, one might expect adolescents from lower SEP backgrounds to use mental health care services more frequently. However, the relationship between SEP and mental health care use is complex. Factors like cost, proximity to care, ability to navigate the healthcare system, and differences in symptom recognition or perceived need for care can all influence whether adolescents access and utilize mental health services.

This study aimed to investigate whether there are socioeconomic differences in mental health care utilization among Swedish adolescents, while taking into account their mental health status as an indicator of their need for care. The researchers hypothesized that SEP might predict mental health care use differently depending on the severity of an adolescent’s symptoms.

The Swedish Healthcare Context

To understand the study findings, it’s helpful to have some context about the Swedish healthcare system:

• Sweden has a decentralized system where regional authorities are responsible for healthcare financing and provision.
• Mental health care is mostly provided through publicly funded facilities.
• Primary care offers early interventions and acts as a gatekeeper to more specialized care.
• Child and Adolescent Psychiatry (CAP) services handle more severe cases, with both outpatient and inpatient care available.
• Healthcare for children under 18 is generally free, except for a small fee at emergency departments.
• There is a national “Healthcare guarantee” policy that aims to ensure timely access to care, including mental health services.

Study Design and Methods

The researchers analyzed data from 3,517 adolescents who were followed from 7th to 9th grade (ages 13-16). They examined the relationship between:

1. Parental socioeconomic position (measured by education level and household income)
2. Adolescents’ estimated need for mental health care (based on self-reported mental health status)
3. Utilization of mental health care services (defined as visits to secondary psychiatric care or receipt of psychotropic medication)

The study used survey data linked to healthcare registry information, allowing the researchers to combine self-reported mental health status with objective measures of healthcare use.

Key variables included:

• Mental health status: Measured using the Strengths and Difficulties Questionnaire (SDQ), categorized as no/mild, moderate, or severe symptoms.
• Socioeconomic position: Parental education (with or without tertiary education) and household income (divided into lowest, middle, and highest tertiles).
• Mental health care use: Any contact with secondary psychiatric care or receipt of psychotropic medication, as well as the number of outpatient visits for those who used services.

The researchers used statistical models to analyze how SEP predicted mental health care use, while considering the moderating effect of mental health status.

Key Findings

The study revealed several important patterns in mental health care utilization among Swedish adolescents:

Overall Socioeconomic Gradient

Consistent with previous research, adolescents from lower SEP families were more likely to report mental health problems compared to their peers from higher SEP backgrounds. They were also more likely to use mental health care services overall.

Differences by Symptom Severity

For adolescents with no or mild symptoms:

• Lower parental education was associated with higher odds of using mental health care services.
• This pattern was largely explained by treatment for ADHD (Attention-Deficit/Hyperactivity Disorder) and ASD (Autism Spectrum Disorders), particularly among boys.

For adolescents with moderate to severe symptoms:

• There were no statistically significant differences in overall mental health care use based on parental education.
• However, for girls with severe symptoms, lower parental education predicted reduced odds of using mental health care for disorders other than ADHD/ASD (such as depression and anxiety).

Number of Outpatient Visits

Among adolescents who did access mental health care:

• Those from lower SEP backgrounds tended to have fewer outpatient visits, particularly for disorders other than ADHD/ASD.
• This pattern was especially pronounced for girls with severe symptoms from the lowest income households, who had significantly fewer outpatient visits compared to their higher-income peers.

Differences by Type of Mental Health Problem

The study found that socioeconomic factors influenced mental health care use differently depending on the type of mental health issue:

• For ADHD/ASD, mental health care use appeared to be more equitable across socioeconomic groups.
• For other mental disorders like depression and anxiety, there were indications of unequal use, particularly among girls from lower SEP backgrounds.

Interpretation and Implications

These findings suggest several important implications for understanding and addressing mental health care access among adolescents:

1. Equitable Care for ADHD/ASD: The more equitable use of mental health care for ADHD/ASD treatment is a positive finding. It suggests that the Swedish healthcare system may be effectively identifying and treating these conditions across socioeconomic groups.

2. Concerns for Girls with Other Mental Disorders: The reduced odds of mental health care use and fewer outpatient visits among girls from lower SEP backgrounds with severe symptoms of disorders like depression and anxiety is concerning. This may indicate unmet mental health needs in this population.

3. Recognition of Symptoms: The study’s authors suggest that the nature of different mental health problems may influence their recognition and subsequent care-seeking. Externalizing problems like ADHD may be more readily noticed by parents, teachers, and others, leading to more equitable care. In contrast, internalizing problems like depression and anxiety may be less visible, relying more on self-recognition or parental awareness, which could vary by SEP.

4. Barriers to Care: For girls from lower SEP backgrounds with severe symptoms, there may be additional barriers to accessing and continuing mental health care. These could include stigma, difficulty recognizing or communicating symptoms, or challenges navigating the healthcare system.

5. Need for Targeted Interventions: The findings highlight the importance of developing targeted interventions to improve mental health care access and utilization for adolescent girls from disadvantaged backgrounds, particularly for disorders like depression and anxiety.

Conclusions

• The study found that estimated needs for mental health care among Swedish adolescents seem to be met relatively equally for the treatment of ADHD/ASD across socioeconomic groups.
• However, there were indications of unequal mental health care use for other disorders, particularly among girls from lower socioeconomic backgrounds with moderate to severe symptoms.
• Further research is needed to understand the specific barriers that may be preventing these girls from accessing or continuing mental health care.
• Policymakers and healthcare providers should consider developing targeted strategies to improve mental health care access and utilization for adolescent girls from disadvantaged backgrounds, especially for disorders like depression and anxiety.