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. Our hypotheses were only partially supported. Firstly, we observed that 37% of the men who had perceived a need for mental healthcare at some time in life 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, i.e. did not receive the care that they needed. 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, and 3) the lack of persistent differences at T2.
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 (38-40) and suicidality (40). 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). 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 (21). However, more research is needed to confirm this result and investigate why non-care-seekers had poorer mental well-being. Is it the lack of treatment in itself or other factors? For example, one block to mental healthcare-seeking is perceived stigma and embarrassment (26, 44, 45), which is in itself associated with poorer quality of life (46), drinking to cope, and social isolation (47).
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, 26)
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 (36, 37). The indicated poorer mental well-being among insufficient care-perceivers may be due to not receiving care of adequate quality (20), as consistent evidence shows a positive association between perceived sufficiency of care and quality of care (27).
However, as we had no measure of clinical sufficiency of the care, it is also possible that insufficient care-perceivers were offered care of adequate standards but did not find it appropriate based on their perceived needs. The perception of need for care is a complex process, impacted by e.g., cultural and religious beliefs, knowledge about mental illnesses, stigmatizing attitudes, and gender norms (48, 49). For example, traditional masculinity norms can make it difficult to identify with a person needing mental health treatment, with a negative impact on men’s adherence and treatment efficacy (21). Masculinity norms can also increase men’s self-stigma, and make men more sceptical and non-adherent to treatment (21). These barriers may negatively impact the perceived sufficiency of the care. The healthcare system should help men to overcome these barriers by providing high-quality mental healthcare adapted to men’s needs. Therefore, more knowledge is needed on what kind of mental healthcare different groups of men find appropriate and sufficient based on their 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 one year later, 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 (35, 50, 51). 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 (50). A Swedish study also showed that the most common reason for refraining from seeking mental healthcare was believing that the condition would resolve by itself (26). 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 (40). 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.
It should be noted that 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. They may have sought and received sufficient care between T1 and T2. We also lack data on informal help-seeking among family and friends and access to other resources (e.g., social, psychological, and economic). Privileged groups with milder conditions may improve their mental well-being using self-help strategies. Other groups of men may be more vulnerable to severe consequences (52), due to social position and/or a greater clinical need for care. This is indicated by our stratified analyses (Table 2). Among those with persistent mental illness, insufficient care-perceivers had poorer mental well-being at both T1 and T2. Among those born outside Nordic countries, non-care-seekers and insufficient care-perceivers had poorer mental well-being than the corresponding groups born in Nordic countries, at both T1 and T2, although the results were not statistically significant. However, these results should be treated with great caution due to the small numbers in the sub-samples. Future studies with larger samples are needed, that allow for stratified analyses of differences among groups of men.
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.
Implications
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 (53). 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 society, including the healthcare system (53).
There is especially a need for an intersectional approach in the design of interventions and research (53, 54) as some groups of men may be at higher risk for poorer mental well-being based on unmet need for mental healthcare, as indicated by our stratified analyses.
Methodological considerations
The major limitation of this study is the use of secondary data. One drawback is that the questions measuring the exposures (i.e., refraining from seeking care, or perceiving the care as insufficient) referred to “any time in life” but were measured at T1. Therefore, potential outcomes, e.g., poorer mental well-being, could have occurred before T1, at T1, and/or at T2. Due to this limitation, and the observational nature of the data, we are unable to draw conclusions about causality. For future studies, we recommend using a more specified time frame for the exposures, e.g., care-seeking within the last 12 months.
The rationale for still using these questions is the lack of previous research within the field. Also, we believe that the participants replied to the questions on care-seeking based on what was their most recent or severe experience, as refraining from seeking care, or perceiving the care as insufficient is not necessarily a binary event. Therefore, these experiences could have had an effect on mental well-being at both T1 and T2.
The longitudinal design, with measurement of mental well-being at both T1 and T2, also has other advantages. Firstly, a difference observed at two time points is more reliable than a difference observed at one time point only, and could imply a more stable detrimental effect. Secondly, the results from T2 allowed us to challenge the results from T1. For example, the lack of persistent differences at T2 highlights a potential uncertainty of the findings at T1. The risk for reverse causality also decreased at T2. At T1, those with poorer mental well-being may be more likely to retrospectively report receiving insufficient care due to current pessimism related to depression (55, 56). Thirdly, without the data from T2 we would not have detected that neither care-seekers and non-care-seekers were fully recovered, as they still had poorer mental well-being than the population mean.
Another aspect to consider is the participation rate of 34%. It 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. Non-participating men have been shown to be less likely to seek care (57), and non-participants have been shown to be more likely to have a psychiatric disorder than participants (58). 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. Also, the relatively low participation rate, and the skewed participation based on sociodemographic characteristics (33) 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 is needed using primary data and more refined methodology, including a more specific time frame for the assessment of the exposures, longer follow-up, and larger sample sizes. However, this study also has some relevant strengths, namely: 1) the relatively large population-based sample of men, 2) inclusion of both refraining from seeking care and perceiving the care as insufficient as exposures 3), access to longitudinal data on mental well-being, 4) the use of the reliable and validated instrument WHO-10 (41, 42), and 5) 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, and the only study from Sweden. Therefore, we believe that this study adds to the literature on men’s mental healthcare-seeking.