We provide rare evidence on psychotherapy non-utilization across age groups across two separate nationwide cohorts of German community-dwelling adults with a focus on the development in old age. In those with perceived need for treatment due to mental health problems (i.e., need factor according to Anderson’s Model of Health Care Use), we hypothesized elevated levels of non-utilization of psychotherapy in older age groups (i.e., predisposing factor) compared with the younger ones. We further assumed the disposing factors gender, living in rural areas and poor general health status and the enabling factors educational status, single habiting, and general health status to be associated with non-utilization of psychotherapy. Moreover, the association with GP visits (i.e., enabling factor) was investigated. Finally, we expected, on average, perceived need for treatment to be increasing over the five years across cohorts.
The rate of perceived need for treatment was significantly elevated from about twelve percent in 2014 to fourteen percent in 2019. Although this effect may be due to an increased awareness of mental health problems in older adults, our results echo recent findings from Germany showing an increase in administrative prevalence of depressive disorders in the outpatient care setting from almost thirteen percent in 2009 to almost sixteen percent in 2017; although this effect was largely due to an relative increase in younger cohorts under 24 years of age . This indicated not directly an increased prevalence of mental health problems over time, but an increase in diagnostics and potentially in mental health service use. Further, we found that in those participants, who reported perceived need for treatment, almost two third of the population saw a psychotherapist. Conversely, one third did not receive treatment by a psychotherapist. In the literature on unmet need for treatment, Nadeem et al.  reported a rate perceived need for treatment of 54.7% in a US sample of depressed low-income women; while only 8.2% received mental health treatment. Seeking for treatment was 62.4% of those having a major depression in a study by Mojtabai et al. ; 31.9% reported an unmet need for treatment. In a study of subclinical depressed participants, 27% received treatment, 33% reported an unmet need, while 40% had no perceived need and the authors conclude that not subclinical depressed individuals may need help for their depressive symptoms .
Regarding the relation of increased age with non-utilization of psychotherapy, there was an increased probability for middle-aged cohorts of not receiving psychotherapy compared with those adults under 26 years of age. In old age, not receiving or using psychotherapy was strongly elevated in the cohort of 65–74 years old and dramatically in those 75 + years of age. This finding is much in line with previous evidence on mental health service research of studies that were conducted 10 years or more in the past [8, 9, 30, 31]. More recent studies support our findings of higher rates of non-utilization of psychotherapy and lower referral rates in older adults than working age adults [10, 32]. In addition, Crabb and Hunsley , for instance, found that compared to depressive individuals aged 45–64 years, those people over 65 years of age with depression were less likely to report a mental health consultation in the past year. This held especially true for psychotherapist, as most consultations were with a GP.
In spite of general awareness about an age-related gap in the non-utilization of mental health services, less is known about its underlying causes. However, past research has identified some relevant factors in the underutilization of mental health services among older adults, such as patients negative stigma and beliefs associated with mental health and mental health care [12, 23], negative self-perceptions of aging , personal beliefs of older adults , unmet needs , lack of professional training and knowledge in geriatrics and aging , and lack of organizational structures such as interdisciplinary approaches and collaborative care models [6, 35, 36]. The vastly lower levels of psychotherapy utilization in older adults relative to the younger cohorts are especially concerning as there are – in principal – plentiful of psychotherapy resources and no additional charges for the patients with the statutory health insurance system in Germany.
With regard to the role of gender in the utilization of psychotherapy, past research has reported mixed results: while Wei et al.  found no gender differences in psychotherapy non-utilization, others reported higher rates in women than in men . Our result endorses gender differences in the utilization of mental health services. Further, the finding is in line with past research acknowledging a series of gender-related barriers in seeking mental health support . Our finding on single habiting may be related to fewer resources of instrumental and emotional spousal and social support, that foster help-seeking behaviour for psychotherapy. In line with previous research, the present study underlines higher non-utilization of mental health services in rural areas . Structural barriers such as availability of and geographic distance from mental health services may be related to a lower utilization of mental health services in rural areas. However, our finding may also reflect differences in attitudes towards seeking mental health services among people living in rural and non-rural areas . Further, we found some evidence of the relation of higher education and psychotherapy, although the picture was not clear. Using Medicare claims data, Wei et al. found in a sample of older adults with depression, older age, high educational attainment, and the structural unavailability of psychotherapy providers to be related with non-utilization of psychotherapy .
Those who reported GP visits were more likely not to use psychotherapy, which was independently of the overall health status. This finding is in line with previous research on both, the key role of GPs in the treatment of mental health problems [36, 40, 41] and findings on a distinct mental health under-treatment by mean of psychotherapy in the primary care setting [35, 42], especially among older adults . Some research found GPs treat patients with depression comprehensively as they are able to take into account the complex comorbidity history of their older patients . Nonetheless, previous findings also proposed a lack of skills and knowledge in mental health among GPs [42, 45, 46]. However, a systematic review and meta-analysis examining the role of GP trainings in depression care and found no improvement in care. Instead, collaborative care models are suggested as a more promising strategy in the improvement of depression care . Strengthening collaborations between GPs and psychotherapists, increasing rates of referrals and improving diagnostics skills and reimbursement would potentially improve rates of psychotherapy utilization in older adults. Finally, our finding of high rates of psychotherapy non-utilization in older adults is especially unsatisfactory as meta-analytical evidence supports the effectiveness of psychotherapy in older adults, although effectiveness varies largely across studies and samples . To sum up, results remain inconclusive and further research is needed in order to examine promising approaches to improve diagnostics and treatment of mental health in primary care, especially for older adults.