This cross-sectional survey study evaluated common mental health needs (depression, anxiety and alcohol problems) in a representative general population sample in Antwerp, Belgium. A total of 1208 people aged 15 to 80 years old participated in the study. It was found that about one in five (22%) has a probable depressive disorder, anxiety disorder or alcohol disorder. Mental disorders were found to be more common among younger age groups, people with a lower education level and people with financial problems. As expected, the presence of mental problems is linked to dysfunction in daily life. In total, our data suggest that a fifth of all individuals suffers from functional problems. This concerns half of the people with a mental health need, but surprisingly, also 12% of those without a positive screening on one of the screening scales indicate that their daily life is at least moderately impacted by psychological problems.
Furthermore, only about one third of people with a probable mental disorder consulted a health care professional for their mental health, resulting in a population prevalence of 14% normative unmet mental health needs. In addition, 14% of the population perceived an unmet mental need themselves, although the predictors of normative and perceived unmet mental health needs differ considerably.
Overall, one in six people discussed mental health related issues with a health care professional within the past year, especially with a psychologist and/or GP. Men, people aged 65 and older, and people born outside of Europe were less likely to use health care for their mental health. Health care use for mental health problems in the general population is higher than generally reported in other studies, where approximately one in ten people use formal health services for their mental health (23-25). This may be due to the broader definition of health care use, namely any contact with a health professional for mental health reasons (incl. emotional problems or substance abuse). It was found that the ones consulting a health professional for their mental health are not necessarily the same as those with a probable mental disorder. Almost two thirds (63.3%) of participants with a probable mental disorder did not consult a professional for their mental health. Because the quantity and quality of care were not taken into account, this approach may even lead to an underestimation of the actual unmet mental health needs. In prior research it was suggested that approximately half of treatments in high-income countries do not meet minimally adequate treatment (MAT) criteria (i.e., eight or more psychotherapy visits or four or more visits to a doctor with pharmacotherapy) (26-28).
Normative unmet mental health needs are on a population level more common among young people, but this can be explained by their higher level of mental health problems. In contrast, only 11% of people aged 65 and older have a mental health problem according to screening scales, but 90% of these cases did not receive any form of care for mental health problems. Consistent with previous research, older people with a mental disorder are less likely to seek help when needed, especially because they tend to underestimate their own needs (29-32). Also a gender difference is present, with 70% of men versus 56% of women with a probable mental disorder who did not seek help for mental health problems, but this result was insignificant in the multivariable logistic regression model.
The population proportion of people with financial problems with unmet mental health needs was higher than the population proportion of people without financial problems with unmet mental health needs because of their higher prevalence of mental health problems. Individuals with financial distress with a mental health problem more often sought help compared to people without financial distress. In line with this finding, a longitudinal study in the UK reported higher levels of treatment with medication and psychological therapy among people from disadvantaged backgrounds (33). Other studies reported an increased risk of unmet needs among people with lower income (4, 34), or reported no clear association (35, 36). Firstly, it must be noted that financial distress was self-reported in this study, and people might differ in the way they define financial difficulties. Secondly, people with more financial resources might have more possibilities for self-care or other alternatives such that professional help is less needed. Finally, the design doesn’t allow to draw causal conclusions, and the interpretation is especially difficult because of the reciprocal relationship between mental illness and poverty (37).
Another remarkable finding is that more than half (54%) of those who discussed mental health related problems with a professional had no current mental health need as assessed by screening questionnaires. Several reasons can account for this finding. First, these individuals may be subthreshold cases or may have a mental health problem that was not assessed in the study. Second, mental health needs were assessed at point-prevalence, while health care contacts for mental health reasons were estimated at 12-month prevalence. It may therefore be possible that some people have had a mental health problem that is already solved. Finally, this may also be an expression of ‘overmet need’. Research has shown that people without a mental disorder account for a significant proportion of healthcare users, but that these individuals often have other need indicators, and generally have fewer visits and use less specialist services (5, 23, 38). People with mental distress receiving some professional help should therefore not be regarded as having ‘overmet need’, as this can alleviate mild mental health problems and prevent problems from worsening.
Unmet mental health needs were also assessed from a subjective perspective. A perceived unmet mental health need is present when someone did not seek care but perceived a need for mental health care (= fully perceived unmet need), or when someone did seek care but felt that this was not sufficient (= partially perceived unmet need). In total, 14.0% perceived an unmet mental health need, of which the majority are fully unmet. When help was received, 23% felt that they were insufficiently helped. In line with previous research, men and older people were less likely to perceive an unmet need for mental health care (9, 14, 39). Contrary to normative unmet needs, individuals experiencing financial distress more often perceived an unmet mental health need, but this can be attributed to the different sample studied (subsample with mental health problem vs. total sample).
When an unmet mental health need was perceived, participants were asked to endorse all reasons for not seeking (extra) help. As expected from the literature, the most frequently reported barriers for not getting help are motivational or attitudinal barriers (4, 15). Two-thirds cited self-reliance as the reason for not seeking help, and nearly a third thought it wouldn't help. A quarter of the people who did not seek help mentioned cost as a barrier. However, among individuals who received help but felt this was insufficient, financial reasons were most often endorsed. This suggests that the cost of mental health care is in Belgium primarily an obstacle to obtaining adequate care as long as needed (e.g., the majority of psychotherapy was not reimbursed at the time of data-collection).
A major advantage of the study is the public mental health perspective. Other strengths of the study are the use of a representative probability sample and the inclusive nature of the study. For example, online participation was possible in six languages including Arabic, and the wider age range allowed 15 to 80-years old to participate. Finally, the study covered a rather small region, allowing local healthcare providers to match their care offer to the mental health needs in the region.
It must be noted that the data collection took place between May and August 2021, which means some covid-19 related freedom-restrictions were still implemented and may have influenced the findings. Prior research showed no statistical difference between met and unmet need for mental health care, but point estimates were suggestive of higher unmet needs among those with a current mental disorder after the lock-down period (40). Comparison with the province of Antwerp in the Belgian Health Interview survey suggests that the prevalence of mental health problems has risen substantially since 2018: probable depression rose from 6% to 10%, anxiety disorder remained the same (11%), and alcohol abuse (based on the CAGE questionnaire only) doubled from 6% to 13% (41, 42). However, no comparable Antwerp data is available on perceived or unmet needs.
Additionally, though validated instruments were used, the exclusive use of symptom screening questionnaires may be considered a limitation. These measures are indicative of mental disorders but tend to overestimate the true prevalence in the population (43, 44). Moreover, only common mental disorders were included. Also, the disorder type and severity were not considered when studying unmet needs. However, this may be relevant, for example as previous research suggests that men may be more likely than women to delay using health care for minor mental health concerns, but that gender effects diminish when problems are more serious (45). Also, people with a substance use disorder tend to be less likely to perceive a need for care and seek treatment (46, 47).
As a final remark, only one quarter of the invited sample participated, despite two postal invitations and the possibility to participate online and offline. However, this response-rate was anticipated and the data were weighted to match the population distribution, also correcting for minor inequalities in non-response across strata.
An important finding is that unmet mental health needs are high, with a population prevalence of 14% for both perceived and normative unmet needs. This is remarkably higher than estimates reported elsewhere, but different definitions and operationalizations complicate comparisons (2, 4). However, the overlap between perceived and normative unmet needs is small. Additional analysis revealed that 116 participants have only a normative unmet need, 121 people have only a perceived unmet need, and merely 48 people (16.8% of those with any normative and/or perceived unmet need) have both a normative and perceived unmet need for mental health care. Moreover, unmet normative and perceived needs are explained by different factors. Especially, more women perceived an unmet need for mental health care, but more men with a probable mental disorder did not seek care. Little differences were found in unmet needs as regards to education and urbanicity. Future research should further explore the link between normative and perceived (unmet) needs and its associated factors. A combination of subjective and objective approaches allows researchers and policymakers to assess the (unmet) need for mental health care on a population level with special attention to the individual perspective.
Further efforts should be made to make mental health care more accessible for everyone. The reported reasons for not seeking or receiving adequate care may provide guidance to policy makers. To ensure that every individual with a mental health need receives adequate care, stepped care principles should be respected such that people with mild needs are helped in generalist or primary care services, and people with more severe needs in specialist services. Information and awareness campaigns remain important to help people overcome motivational barriers to mental health care. Also financial barriers to obtaining extra help need to be addressed. Finally, the totality of health and social care needs of people with mental health problems should be addressed as well, so that not only the ‘treatment gap’ but the whole mental health ‘care gap’ can be reduced (3).