This is the first longitudinal study on a population-based sample of men in Sweden investigating whether A) refraining from seeking mental healthcare, and B) perceiving care as insufficient when seeking it are detrimental to men’s mental well-being (see Fig. 1). Our hypotheses were only partially supported. Firstly, we observed that 37% of the men who had perceived a need for mental healthcare had refrained from seeking care. In line with hypothesis A1, they had poorer mental well-being at T1, compared to those who sought care. However, in contrast to hypothesis A2, they did not have poorer mental well-being one year later. Secondly, we observed that 29% of the men who had sought care perceived that they had received insufficient care. In line with hypothesis B1, they had poorer mental well-being at T1, compared to those who perceived it as sufficient. However, this result was not statistically significant when adjusting for potential confounders, and the hypothesis was rejected. Likewise, insufficient care-perceivers did not have poorer mental well-being one year later, in contrast to hypothesis B2. Therefore, hypothesis A1 was confirmed, but hypotheses A2, B1, and B2 were rejected (see Fig. 1). Henceforth, we will discuss 1) the poorer mental well-being among non-care-seekers at T1, 2) the indication of poorer mental well-being among insufficient-care-perceivers at T1, 3) the lack of persistent differences at T2, and 4) the implications of the findings.
Poorer mental well-being among non-care-seekers at T1
The observed poorer mental well-being among non-care-seekers at T1 is worrying, as poor mental well-being using WHO-10 is associated with a higher likelihood for depression (36–38) and suicidality (38). This result is in line with the large body of research showing the benefits of receiving treatment (4, 5). More importantly, it supports the suggestion that refraining from seeking mental healthcare is detrimental for men’s mental well-being also on a population level (7–11). More research is needed to confirm this finding and investigate why non-care-seekers had poorer mental well-being. However, the poorer mental well-being may reflect a risk for more severe consequences, such as premature death and suicide, and the use of maladaptive coping strategies, such as high alcohol consumption (7), previously explained by adherence to health-hazardous masculinity norms (19).
It should be noted that the difference in mental well-being scores between non-care-seekers and care-seekers at T1 was small. However, even small differences may have major implications on population level given the high prevalence of depression, anxiety- and alcohol use disorders (1), and refraining from seeking mental healthcare among men (6, 24). In addition, this study only investigated differences in mental well-being among need-perceivers. However, a large proportion of men with depression do not perceive a need for care (24, 42). Potentially, this group may suffer from even poorer outcomes. Future studies should investigate differences in outcomes between need-perceivers and non-need-perceivers with a clinical need for care.
Indication of poorer mental well-being among insufficient care-perceivers at T1
Even in insufficient care-perceivers, the t-tests and the linear regression analysis showed poorer mental well-being at T1, compared to sufficient care-perceivers. However, this result was not statistically significant when controlling for sociodemographic and health variables (Table 3). This is probably due to the small sample in this sub-group analysis, as the sensitivity analysis on a larger sample showed a statistically significant difference (see Supplementary Table 3, Additional file 3). Our result is in line with previous research that has shown an association between dissatisfaction with care and depression (34, 35). The indicated poorer mental well-being among insufficient care-perceivers may be due to not receiving care of adequate quality (18), as consistent evidence shows a positive association between perceived sufficiency of care and quality of care (25). Another possible explanation is that insufficient care-perceivers were more sceptical about treatment due to masculinity norms, and therefore did not adhere to treatment (19). Masculinity norms have been shown to be a barrier to effective treatment also among care-seeking men (19). The healthcare system should help men to overcome these barriers by providing high-quality mental healthcare adapted to men’s needs.
No persistent differences in mental well-being at T2
Although the expected differences in mental well-being between non-care-seekers and care-seekers, and insufficient care-perceivers and sufficient care-perceivers, were observed at T1, we found no differences at T2. This result is in line with previous studies showing that the majority of those with common mental disorders who do not seek treatment remit (33, 43, 44). Results from a longitudinal study on men and women showed that among persons with untreated depression, anxiety or substance disorder, 50% remitted within three years (43). However, our results do not support any complete remission of symptoms, as both non-care-seekers and care-seekers (regardless of the perceived sufficiency of the care) still had mean mental well-being scores below the population mean at T2 (15.7, and 15.8, compared to the population mean 18.9). This is worrying, as the population mean should be the goal for complete remission (38). The lack of full recovery at T2 highlights a need for improved mental healthcare, but also a need to target other societal factors that may have greater importance for men’s mental well-being.
In sum, this study gives some empirical evidence to support the hypotheses of detrimental outcomes of refraining from seeking mental healthcare and of perceiving the care as insufficient when seeking it among men in Sweden. However, the relatively small differences at T1 and the lack of persistent differences at T2 point in another direction.
The small and non-persistent differences observed in this study could reflect a limited ability of the mental healthcare services to improve men’s mental well-being. Other factors may be more important. Masculinity norms have previously been pointed out as the cause of men’s reluctance to seek care, and other maladaptive coping strategies (7). WHO recently called for changes in masculinity norms on a societal level to improve men’s mental well-being (45). To reach men there is a need for outreach strategies through media, workplaces, pubs, and sports associations. Changes in masculinity norms needs to be brought about in the healthcare system and in society (45). Changes in society will probably have a greater effect on men’s mental well-being than focusing on mental healthcare only but both are important.
As men with common mental disorders are a heterogeneous group there is especially a need for an intersectional approach in the design of interventions and research (45, 46). Based on their social positions, some groups of men are more vulnerable to severe consequences (47), e.g. of not receiving treatment. This is indicated by our finding showing that non-care-seekers and insufficient care-perceivers born outside Nordic countries had poorer mental well-being than the corresponding groups born in Nordic countries, at both T1 and T2 (Table 2). However, these results were not statistically significant due to low statistical power in the stratified analysis. Future studies are needed, using larger population-based samples that allow for intersectional analyses of differences among men.
This study has several limitations. Firstly, we cannot draw conclusions about causality. This is partly due to lack of data on the exact time of the exposures, i.e. when participants had refrained from seeking care, or perceived the care as insufficient, as the questions referred to “any time in life”, but were measured at T1. Outcomes of not receiving treatment, e.g. poorer mental well-being, could therefore have occurred before T1. A reversed causality is also plausible, with those with poorer mental well-being at T1 being more likely to report receiving insufficient care due to general pessimism related to depression (48, 49). Secondly, we lack data on care-seeking between T1 and T2, which could explain the improved mental well-being of non-care-seekers and insufficient care-perceivers, as they may have sought and received sufficient care at T2. Thirdly, the participation rate of 34% may be problematic if participation was selective, e.g. if the association between the exposures and the outcome was stronger among non-participants. There is some research pointing in this direction. A Swedish study found that non-participating men were less likely to seek care (50). A Finnish study showed that non-participants were more likely to have a psychiatric disorder than participants (51). This is in line with our finding that those lost to follow-up were more likely to have poor mental well-being and persistent mental illness. However, we found no differences in care-seeking. Plausibly, non-participants share characteristics related to the study’s exposures and outcomes, e.g. belonging to groups in adverse life situations who would benefit the most from treatment. Therefore, this study could have underestimated the negative effect of not receiving care. Fourthly, the relatively low participation rate, and the skewed participation based on sociodemographic characteristics (31) may have contributed to the limited statistical power in the adjusted and stratified analyses, leading to a risk of undetected true differences, i.e. a type II error.
In sum, due to these limitations the result should be generalised with caution. Future research with larger sample sizes, longer follow-up, and more refined methodology is needed. However, this study also has some relevant strengths, namely: 1) the relatively large population-based sample of men, 2) access to longitudinal data on mental well-being, 3) the use of the reliable and validated instrument WHO-10 (39, 40), and 4) stratified data on sociodemographic and health characteristics. In addition, this is one of the very few population-based studies investigating potential detrimental outcomes of not receiving sufficient mental healthcare among men.