In Quebec, few data are available that report on the needs of the older adult population with regard to health services for mental health problems. The Enquête sur la Santé des Aînés (ESA) study conducted in 2005–2006 showed that in Quebec, nearly 13 per cent of the community-dwelling population aged 65 years and over presented a mood or anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria (Préville, Boyer, Grenier, Dubé, Voyer, Punti, et al., Reference Préville, Boyer, Grenier, Dubé, Voyer and Punti2008). This represented more than 100,000 people in 2005, a prevalence rate as important as the one observed in the adult population. Although the importance of mental health problems in the older adult population—and the need to improve the accessibility and the quality of mental health services—is recognised, the evaluation of mental health services and the needs of this population has received little attention in Canada. Given the aging population in the next 20 years and the economic burden on the public health sector associated with service use, it becomes essential to provide decision makers with conclusive data on the treatment-seeking behaviour of the elderly population.
The aim of this study was to document the proportion of the older adult population in Quebec that received health services for their psychological distress symptoms as well as the proportion whose needs were potentially not met. In this study, we were also interested in documenting the association between socio-demographic characteristics and the use of health services for psychological distress symptoms in the elderly.
An important number of mood and anxiety disorders are masked in the aged population, according to several researchers (Beekman, Deeg, Braam, Smit, & Van Tilburg, Reference Beekman, Deeg, Braam, Smit and Van Tilburg1997; Lebowitz et al.; O’Connor, Rosewarne, & Bruce, Reference O’Connor, Rosewarne and Bruce2001; Simon & Von Korff, Reference Simon and Von Korff1991; Von Korff, Katon, & Lin, Reference Von Korff, Katon, Lin, Sartorius and Goldberg1990; Wang et al., Reference Wang, Lane, Olfson, Pincus, Wells and Kessler2005; Wang, Berglund, Olfson, & Kessler, Reference Wang, Berglund, Olfson and Kessler2004). Moreover, even though depressed, older adults tend to report their dysphoric mood less frequently than younger adults (Gallo, Anthony, & Muthen, Reference Gallo, Anthony and Muthen1994; Klap, Unroe, & Unützer, Reference Klap, Unroe and Unützer2003); instead, they pay more attention to their physical symptoms (Gallo & Rabins, Reference Gallo and Rabins1999; O’Connor, Rosewarne, & Bruce, Reference O’Connor, Rosewarne and Bruce2001; Parashos, Stamouli, Rogakou, Theodotou, Nikas, & Mougias, Reference Parashos, Stamouli, Rogakou, Theodotou, Nikas and Mougias2002; Sheehan, Bass, Briggs, & Jacoby, Reference Sheehan, Bass, Briggs and Jacoby2003). Several individuals and their families, especially among the current cohort of older adults, view psychological disorders as stigmatizing and, therefore, deny their existence (Gurland & Toner, Reference Gurland, Toner and Eisdorfer1982; Mechanic, Angel, & Davies, Reference Mechanic, Angel and Davies1991; Robb, Haley, Becker, Polivka, & Chwa, Reference Robb, Haley, Becker, Polivka and Chwa2003; Ruegg, Zisook, & Swerdlow, Reference Ruegg, Zisook and Swerdlow1988; Sarkisian, Lee-Henderson, & Mangione, Reference Sarkisian, Lee-Henderson and Mangione2003; Shulman, Reference Shulman1989; Zemore & Eames, Reference Zemore and Eames1979). Consequently, this view has a negative impact on individuals’ intention to consult (Barney, Griffiths, Jorm, & Christensen, Reference Barney, Griffiths, Jorm and Christensen2006), which could have short- and long-term consequences for the health of the elderly (Gallo, Rabins, Lyketsos, Tien, & Anthony, Reference Gallo, Rabins, Lyketsos, Tien and Anthony1997). In addition, this phenomenon also has an impact on health care costs (Greenberg, Kessler, Birnbaum, Leong, Lowe, Berglund, et al., Reference Greenberg, Kessler, Birnbaum, Leong, Lowe and Berglund2003; Schlesinger, Mumford, Glass, & Sharfstein, Reference Schlesinger, Mumford, Glass and Sharfstein1983; Simon & Katzelnick, Reference Simon and Katzelnick1997).
When the elderly do seek consultation for a mental health problem, they more often use the general medical sector (Blazer, Reference Blazer1993; Issakidis & Andrews, Reference Issakidis and Andrews2006; Mickus, Colenda, & Hogan, Reference Mickus, Colenda and Hogan2000; Robb, Haley, Becker, Polivka, & Chwa, Reference Robb, Haley, Becker, Polivka and Chwa2003). Several studies, however, showed that general practitioners do not detect most of their patients’ psychiatric problems, particularly mood and anxiety disorders (Crawford, Prince, Menezes, & Mann, Reference Crawford, Prince, Menezes and Mann1998; German, Shapiro, & Skinner, Reference German, Shapiro and Skinner1985; Pfaff & Almeida, Reference Pfaff and Almeida2005; Rapp, Parisi, Walsh, & Wallace, Reference Rapp, Parisi, Walsh and Wallace1988; Volkers, Nuyen, Verhaak, & Schellevis, Reference Volkers, Nuyen, Verhaak and Schellevis2004; Waxman, Carner, & Klein, Reference Waxman, Carner and Klein1984). One explanation is that physicians tend to normalize depressive and anxiety symptoms reported by their elderly patients (Gallo, Ryan, & Ford, Reference Gallo, Ryan and Ford1999; Mackenzie, Gekoski, & Knox, Reference Mackenzie, Gekoski and Knox1999; Zylstra & Steitz, Reference Zylstra and Steitz2000) and, as a result, do not refer patients to mental health services (Crawford et al., Reference Crawford, Prince, Menezes and Mann1998; Gallo et al., Reference Gallo, Ryan and Ford1999).
In studying the service use among individuals presenting psychological distress symptoms, studies found that diagnosis alone was a poor predictor of health services use (Leaf, Bruce, Tischler, Freeman, Weissman, & Myers, Reference Leaf, Bruce, Tischler, Freeman, Weissman and Myers1988; Mechanic, Angel, & Davis, Reference Mechanic, Angel and Davies1991; Zola, Reference Zola1966). Some studies reported that women sought treatment for emotional problems more than men did (Crabb & Hunsley, Reference Crabb and Hunsley2006; Robins, Locke, & Regier, Reference Robins, Locke, Regier, Robins and Regier1991; Smith, McGovern, & Peck, Reference Smith, McGovern and Peck2004; Swartz, Wagner, Swanson, Burns, George, & Padgett, Reference Swartz, Wagner, Swanson, Burns, George and Padgett1998). This association could in part be explained by the fact that women exhibit mood and anxiety disorders more often than men (Henderson, Andrews, & Hall, Reference Henderson, Andrews and Hall2000; Kessler, Berglund, Demler, Jin, Merikangas, & Walters, Reference Kessler, Berglund, Demler, Jin, Merikangas and Walters2005). Researchers have also reported that age is associated with health service use for mental health problems, adults receiving treatment more often than young and older adults (Alonso, Angermeyer, Bernert, Bruffaerts, Brugha, Bryson, et al., Reference Alonso, Angermeyer, Bernert, Bruffaerts, Brugha and Bryson2004; Crabb & Hunsley, Reference Crabb and Hunsley2006; Robb et al., Reference Robb, Haley, Becker, Polivka and Chwa2003; Robins et al., Reference Robins, Locke, Regier, Robins and Regier1991; Smith et al., Reference Smith, McGovern and Peck2004; Swartz et al., Reference Swartz, Wagner, Swanson, Burns, George and Padgett1998; Wetherell, Kaplan, Kallenberg, Dresselhaus, Sieber, & Lang, Reference Wetherell, Kaplan, Kallenberg, Dresselhaus, Sieber and Lang2004). Other researchers also found an association between education and the use of general medical services for mental health problems, suggesting that educated people report fewer psychological distress symptoms and that they do use specialized health services for their psychological problems (Robins et al., Reference Robins, Locke, Regier, Robins and Regier1991; Swartz et al., Reference Swartz, Wagner, Swanson, Burns, George and Padgett1998; Ten Have, Oldehinkel, Vollebergh, & Ormel, Reference Ten Have, Oldehinkel, Vollebergh and Ormel2003; Veroff, Kulka, & Douvan, Reference Veroff, Kulka and Douvan1981). Finally, other studies suggested that in a context where health services are accessible to all (as in Quebec), low-income groups do not use health services for their mental health problems more often than those with higher incomes (Préville, Potvin, & Boyer, Reference Préville, Potvin and Boyer1998; Wang et al., Reference Wang, Lane, Olfson, Pincus, Wells and Kessler2005).
Furthermore, it has been shown that separated or divorced people and those living alone or with little social support, consult more often for psychological distress symptoms (Crabb & Hunsley, Reference Crabb and Hunsley2006; Leaf et al., Reference Leaf, Bruce, Tischler, Freeman, Weissman and Myers1988; Ten Have, Vollebergh, Bijl, & Ormel, Reference Ten Have, Vollebergh, Bijl and Ormel2002; Tischler, Henisz, Myers, & Boswell, Reference Tischler, Henisz, Myers and Boswell1975a, Reference Tischler, Henisz, Myers and Boswell1975b; Wang et al., Reference Wang, Lane, Olfson, Pincus, Wells and Kessler2005). In addition, the presence of stressful life events involving physical, social, or economic losses could be more frequent among the elderly using health services for their mental health problems (Phillips & Murrell, Reference Phillips and Murrell1994). Living in a rural area could also have negative consequences on individuals’ access to health services for mental health problems (Issakidis & Andrews, Reference Issakidis and Andrews2006; Wang et al., Reference Wang, Lane, Olfson, Pincus, Wells and Kessler2005).
Method
Data used in this study came from a cross-sectional survey, the Enquête sur la Santé des Aînés (ESA) study, conducted in 2005–2006. In that study, researchers used a probabilistic sample (n = 2,811) of French-speaking community-dwelling older adults (94% of the Quebec population speaks French) to document the prevalence of moderate or severe psychological distress episodes in the older adult population and their use of health services for their symptoms. Subjects living in Quebec’s northern regions were excluded on feasibility grounds; in 2005, 10 per cent of the elderly population resided in these regions.
We used a random-dialling method to develop the study’s sampling frame, which included stratification according to three geographical areas—(1) metropolitan, (2) urban, and (3) rural—to take into account regional variations in the Quebec health service system. In each geographical area, we derived a proportional sample of households on the basis of Quebec’s 16 administrative regions. We also used a random-sampling method to select only one older adult (65 years or over) within the household. The response rate for this study was 66.5 per cent.
Procedure
We collected data as follows. First, a health professional contacted potential respondents by phone to describe the study’s objectives and length, answer questions, and ask them to participate in an in-home interview. Next, we sent a letter describing the study to reassure the potential participants about the credibility of the investigation and of the interviewer. Appointments were then made with those who volunteered. The interviewers were health professionals (n = 20), staff members of a national polling firm. In preparation for the interviews, they were given two days’ training by the principal investigator on administering the ESA computer-assisted questionnaires. Respondents were offered CAN$15 compensation for their participation.
The in-home interviews, which lasted 90 minutes on average, took place within two weeks of initial contact. Written consent to conduct the interview was obtained at the beginning of the interview from all volunteers. Because memory problems affect the accuracy of the information given and performance on psychological questionnaires (Burke, Houston, Boust, & Roccafortte, Reference Burke, Houston, Boust and Roccafortte1989; Kafonek, Ettinger, Roca, Kittner, Taylor, & German, Reference Kafonek, Ettinger, Roca, Kittner, Taylor and German1989), interviewers excluded those individuals presenting severe or moderate cognitive problems on the basis of the Mini-Mental State Examination (a score < 22) (Crum, Anthony, Bassett, & Folstein, Reference Crum, Anthony, Bassett and Folstein1993; Folstein, Folstein, & McHugh, Reference Folstein, Folstein and McHugh1975) (n = 27) at the interview’s start. Thereafter, subjects presenting no moderate or severe cognitive problems (n = 2,784) were invited to respond to the ESA questionnaires (Table 1). The research procedure was previously reviewed and authorized by the Sherbrooke Geriatric University Institute Ethics Committee.
Table 1: Respondents’ socio-demographic and mental health characteristics
Measures
We measured the respondent’s mental health status by means of a computer-assisted questionnaire: the ESA Diagnostic Questionnaire (ESA-Q), which was developed by the research team, based on DSM-IV criteria (APA, 1994). The ESA-Q is similar to the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI), which demonstrated satisfactory reliability and validity (Bucholz, Marion, Shayka, Marcus, & Robins, Reference Bucholz, Marion, Shayka, Marcus and Robins1996; Clayer, McFarlane, & Wright, Reference Clayer, McFarlane and Wright1992; Erdman, Klein, Greist, Skare, Husted, Robins, et al., Reference Erdman, Klein, Greist, Skare, Husted and Robins1992; Levitan, Blouin, Navarro, & Hill, Reference Levitan, Blouin, Navarro and Hill1991; Murphy, Monson, Laird, Sobol, & Leighton, Reference Murphy, Monson, Laird, Sobol and Leighton2000; Robins, Helzer, Croughan, & Ratcliff, Reference Robins, Helzer, Croughan and Ratcliff1981; Robins, Helzer, Orvaschel, Anthony, Blazer, Burnami, et al., Reference Robins, Helzer, Orvaschel, Anthony, Blazer, Burnami, Eaton and Kessler1985; Wittchen, Robins, Cottler, Sartorius, Burke, & Regier, Reference Wittchen, Robins, Cottler, Sartorius, Burke and Regier1991). The complete definition of the disorders studied in the ESA survey has been reported previously (Préville et al., Reference Préville, Boyer, Grenier, Dubé, Voyer and Punti2008). For our analysis, we included the following psychiatric disorders: major depression, minor depression, mania, specific phobia, social phobia, agoraphobia, panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder.
The respondents’ use of health services for their psychological distress symptoms was measured at the end of each ESA diagnosis module with the following questions: (1) “During the past 12 months, did you consult a general practitioner or another health professional about the symptoms you just reported?” (2) “Who did you consult the first time about these symptoms (family doctor, other general practitioner, specialist, psychologist, social worker, nurse, other)?” (3) “Have you been referred to other health professionals for these symptoms (Yes/No)?” (4) “Did you receive a drug prescription for these symptoms (Yes/No)?” (5) “Did you have your prescription filled up (Yes/No)?”, and (6) “Did you stop your drug treatment (Yes/No)?”.
The social support measure we applied in this study is an index based on the responses to three questions: (1) “In your environment, is there someone you can confide in or talk to freely about your problems?”; (2) “Is there someone in your family or circle of friends who could assist you in time of need?”; and (3) “Is there someone you feel close to, a family member or friend, who shows affection towards you?”. Because the majority of the respondents had three sources of support, we defined two categories: (1) absence of at least one of these sources of social support, and (2) presence of the three sources of social support measured. Other studies showed that this index of perceived social support is significantly correlated with respondents’ psychological distress status, physical health status, and psychotropic drug use (Préville, Hébert, Boyer, & Bravo, Reference Préville, Hébert, Boyer and Bravo2001; Préville, Hébert, Bravo, & Boyer, Reference Préville, Hébert, Bravo and Boyer2001).
To measure the presence of stressful life events, we used the DHS-30 items version adapted in French for the elderly from the Daily Hassles Scale (Kanner, Coyne, Schaefer, & Lazarus, Reference Kanner, Coyne, Schaefer and Lazarus1981; Vézina & Giroux, Reference Vézina and Giroux1988). The DHS-30 items questionnaire refers to hassles in different areas of life, such as family, work, health, friends, and so on. Subjects are asked to score the severity of each hassle that has occurred in the last month on a 5-point scale ranging from 1 (not at all severe) to 5 (extremely severe). We calculated an index of stress by dividing the sum of the severity scores on the 30 items by the total number of items reported. The daily hassles stress index varies from 0 to 5 and was dichotomized as follows: (1) low level (< 2, the median score) of stress experienced during the last month; (2) high level (≥ 2) of stress experienced during the last month. The validity study of this index showed that indicators of stress related to physical health contribute significantly to the score on this index in the elderly population (DeLongis, Coyne, Dakof, Folkman, & Lazarus, Reference DeLongis, Coyne, Dakof, Folkman and Lazarus1982; Kanner et al., Reference Kanner, Coyne, Schaefer and Lazarus1981; Monroe, Reference Monroe1983; Weinberger, Hiner, & Tierney, Reference Weinberger, Hiner and Tierney1987).
To determine the respondents’ physical health status, we measured the number of chronic health problems they reported according to the International Classification of Diseases (ICD-10). The socio-demographic characteristics we examined in this study were as follows: (1) age, (2) gender, (3) marital status, (4) education, (5) income, and (6) region of residence. Level of education was categorized as (1) less than 7 years, or (2) 8 years and over. The family annual income was measured as (1) less than $15,000, or (2) $15,000 and over. The region of residence was categorized based on population density criteria as (1) metropolitan (≥ 100 000 h.), or (2) urban (≥1,000 h.) and rural (< 1,000 h.), according to the definitions of the Institut de la Statistique du Québec (Institut de la Statistique du Québec, 2005).
Analyses
Data were weighted to ensure that the analysis reflected the true proportions of older adults in each region and each geographical area. Weights were determined based on (1) the probability of selection of the administrative region in the geographic area [π(a)]; (2) the conditional probability of selection of the household in the administrative region [π(b/a)]; and (3) the conditional probability of selection of the subject in the household [π(c/ab)]. The weight (w) attributed to each subject represented the inverse of its probability of selection {1/[π(abc)]}. The weighted sample included 2,784 older adults living at home. The mean and median sampling design effects were 0.94 and 0.95 respectively.
We applied a logistic regression analysis to describe the associations between the independent variables we studied and the respondents’ use of health services for psychological distress symptoms (Hosmer & Lemeshow, Reference Hosmer and Lemeshow1989). As a measure of association, we used the odds ratio and its confidence interval. All hypotheses were tested at the 5 per cent significance level.
Results
Based on the weighted sample, the respondents’ mean age was 73.8 years (SD = 6.1), and 59 per cent of the respondents were women. Among the socio-demographic factors studied, 46.0 per cent of respondents were married; 84.2 per cent reported all three sources of social support; 18.7 per cent reported an annual income lower than $15,000; 23.5 per cent of respondents had fewer than 8 years of education, and 44.6 per cent resided in a metropolitan area. Finally, 59.4 per cent of respondents reported a high level of daily hassles during the last month, and 12.9 per cent reported psychological distress symptoms that met criteria for a DSM-IV diagnosis.
As Figure 1 indicates, 12.8 per cent (n = 355) of respondents used health services for psychological distress symptoms during the 12-month period preceding the ESA study. This represents 35.3 per cent of the respondents who reported at least one psychological distress symptom and 42.4 per cent of the respondents having a probable DSM-IV diagnosis. When we restricted the analysis to the data specifically related to the use of health services for psychological distress symptoms (n = 966), our results indicate that the use of health services did not vary significantly according to age, gender, income, and education when the level of psychological distress symptoms was statistically controlled (see Table 2). The results, however, do indicate that older adults living in an urban and rural area were more likely to seek consultation as opposed to those living in metropolitan areas (OR: 1.39; CI: 1.02-1.90), as did respondents living alone (widowed, separated, divorced, or single) (OR: 1.58; CI: 1.14-2.18) compared to those who were married. The results of this study also indicate that the use of health services was lower among those reporting minimal social support (OR: 0.64; CI: 0.43-0.95). In addition, the respondents reporting a high level of daily hassles during the previous month (OR: 1.99; CI: 1.42-2.80) and those having a probable psychiatric disorder according to the DSM-IV (OR: 1.50; CI: 1.11-2.03) were more likely to have consulted for their symptoms in the previous 12 months.
Figure 1: Respondents’ use of health services for specific categories of respondents
Table 2: Use of health services for psychological distress symptoms according to respondents’ socio-demographic and health characteristics
* Indicate the reference category for calculating the odd ratio
** Adjusted odds ratio
Among the respondents (n = 341) who reported having used health services for their psychological distress symptoms, 93 per cent consulted a physician for their symptoms. A large majority (79.0%) consulted a general practitioner; a few reported having consulted a psychologist (5.0%), social worker (2.4%), or nurse (0.7%) (see Figure 2a).
Figure 2a: Type of professional visited by the respondents reporting to have used health services for psychological distress symptoms (n = 342)
Figure 2b: Type of professional referred to by the general practitioner first consulted (n = 146)
Among the respondents who consulted a general practitioner (n = 270), most were referred to a specialist (49.1%) or psychiatrist (13.1%); 19.4 per cent were referred to a psychologist, 5.9 per cent were referred to another general practitioner, and 7.0 per cent were referred to a social worker or nurse (3.3%) (see Figure 2b). Among the respondents reporting at least one psychological distress symptom but not meeting the DSM-IV diagnosis threshold, 30.6 per cent reported having had consulted a physician for their symptoms in the past year (see Figure 3). Nearly 61 per cent of those who visited a physician received a prescription for their symptoms, and 53.4 per cent were referred to another health professional. Among the respondents with a probable DSM-IV disorder, 5.1 per cent first consulted with a non-physician health professional. Among respondents with a probable DSM-IV disorder, 37.3 per cent consulted a physician and 66.4 per cent of those received a prescription for the symptoms they experienced; 38.4 per cent were referred to another health professional (see Figure 3). With regard to medication use, almost all (98.9%) of respondents had their prescriptions filled, but about 14 per cent reported having subsequently stopped their treatment.
Figure 3: Proportion of respondents who used health services for psychological distress symptoms in the previous 12 months
Discussion
The aim of this study was to document the use of health services for psychological distress symptoms in the community-dwelling elderly population in Quebec. Our results indicate that 34.7 per cent (n = 966) of respondents reported at least one psychological distress symptom. Among them, 34.7 per cent met the DSM-IV criteria for a mood or anxiety disorder. In addition, 35.3 per cent of those having at least one symptom reported having used health services for the symptoms they experienced, and 42.4 per cent of those having symptoms meeting DSM-IV criteria reported having used health services for their symptoms. This result is similar to the proportion of users reported in other surveys using samples of the general population who were 18 years and older (Lefebvre, Lesage, Cyr, Toupin, & Fournier, Reference Lefebvre, Lesage, Cyr, Toupin and Fournier1998; Wang et al., Reference Wang, Lane, Olfson, Pincus, Wells and Kessler2005). Of the respondents who consulted, most (72.1%) visited their family doctor, and a few were referred to a non-medical health professional. Our findings are similar to those reported in other epidemiological surveys (Crabb & Hunsley, Reference Crabb and Hunsley2006; Klap et al., Reference Klap, Unroe and Unützer2003; Mickus et al., Reference Mickus, Colenda and Hogan2000; Phillips & Murrell, Reference Phillips and Murrell1994; Robb et al., Reference Robb, Haley, Becker, Polivka and Chwa2003).
Our results show that the elderly with a probable psychiatric disorder are more likely to contact the health care system for their symptoms than sub-clinical cases. When the number of psychological distress symptoms was controlled, the analysis suggested that unmarried people are more likely to use services than those who are married. These results are in agreement with the Canadian Community Health Survey results (Crabb & Hunsley, Reference Crabb and Hunsley2006), in which a person’s not being married significantly predicted mental health consultations with a family physician. In addition, the results support the hypothesis that a high level of social support increases the probability of using health services for psychological distress symptoms among the elderly and suggest that supporting social network would facilitate services use by providing assistance and information (Vasiliadis, Tempier, Lesage, & Kates, in press). These results are congruent with the idea that mental health services utilization is influenced not only by symptoms but also by psychological and social variables.
The data also show that a high level of daily hassles significantly increases the probability of consulting for psychological distress symptoms among the elderly. This result is in agreement with the study by Phillips and Murrell (Reference Phillips and Murrell1994), who found that stressful life events occurred more frequently among the elderly who sought health services for their mental health problems.
Contrary to findings from other studies, our results do not show an association between gender and health service use for psychological distress symptoms, and thus do not support the gender differential hypothesis of health services use for psychological distress symptoms suggested by other researchers (Alonso et al., Reference Alonso, Angermeyer, Bernert, Bruffaerts, Brugha and Bryson2004; Crabb & Hunsley, Reference Crabb and Hunsley2006; Smith et al., Reference Smith, McGovern and Peck2004). Furthermore, income levels of the elderly in this study were not associated with health service use for psychological distress symptoms. The results we obtained are consistent with findings reported by Bland, Newman, and Orn (Reference Bland, Newman and Orn1997) and also with the hypothesis that individuals from lower social classes have a more functional definition of their health: they tend not to consult health services when their psychological distress symptoms do not interfere with the performance of their social roles (Holzer, Shea, Swanson, Leaf, Myers, George, et al., Reference Holzer, Shea, Swanson, Leaf, Myers and George1986; Wells, Manning, Duan, Newhouse, & Ware, Reference Wells, Manning, Duan, Newhouse and Ware1986). Finally, as the study by Bland and colleagues (Reference Bland, Newman and Orn1997) and Klap and colleagues (Reference Klap, Unroe and Unützer2003) showed, we found no evidence that education acts as a predisposing factor of health services use for psychological distress symptoms.
Our interpretation of the results should be balanced against some of the study’s limitations. First, the study was cross-sectional; therefore, we were unable to determine the direction of the relationships between predisposing and facilitating factors and use of health services for psychological distress symptoms. Second, the data used were self-reported and may include an information bias related to the respondents’ attitudes at the time of the survey. Despite these limitations, our analyses were conducted on a representative sample of Quebec’s older-adult general population. Also, our data allowed us to study health service use reported specifically for psychological distress symptoms, contrary to other studies that generally document the association between health services use and psychological distress symptoms but without controlling for the reason each specific health services visit was made (Alonso et al., Reference Alonso, Angermeyer, Bernert, Bruffaerts, Brugha and Bryson2004; Issakidis & Andrews, Reference Issakidis and Andrews2006; Phillips & Murrell, Reference Phillips and Murrell1994; Smith et al., Reference Smith, McGovern and Peck2004; Wang et al., Reference Wang, Lane, Olfson, Pincus, Wells and Kessler2005). This might explain why, in our study, we did not find an association between gender and the use of health services for psychological distress symptoms.
Conclusion
Our results show that 57 per cent of probable DSM-IV active cases at the time of the ESA study did not consult for their symptoms during the previous 12-month period. This result leads us to conclude that a large proportion of elderly mental health needs in Quebec are potentially not being met. However, longitudinal research on the persistence and remission of the elderly population’s psychological distress symptoms appears to be necessary in order that researchers avoid misinterpreting findings on unmet needs. Further studies based on incident cases might also contribute to our understanding of individual, environmental, and organisational factors related to non-use of health services among individuals with a probable psychiatric disorder.
The ESA study showed that 37 per cent of the elderly with a probable DSM-IV disorder consulted a physician for their symptoms. Further studies should focus on the performance of the health care system to respond to the needs of the elderly. Patient-based studies focusing on the quality of the mental health services offered in the Quebec primary health care sector are needed, and will help decision makers in their future revision of the Quebec mental health plan that was implemented in 2005.
