Inequities in access to depression treatment: results of the Brazilian National Health Survey – PNS

Lopes et al. International Journal for Equity in Health (2016) 15:154 DOI 10.1186/s12939-016-0446-1 RESEARCH Open Access Inequities in access to depression treatment: results of the Brazilian National Health Survey – PNS Claudia Souza Lopes1*, Natália Hellwig1, Gulnar de Azevedo e Silva1 and Paulo Rossi Menezes2 Abstract Background: Despite depression being one of the most prevalent mental disorders in the world, access to treatment is still insufficient, especially in low- and middle-income countries. The aim of this study is to investigate differences in access to treatment for depression according to socio-demographic characteristics, geographical area and multi-morbidity in a nationally representative sample of individuals with depression. Methods: This study analyses data from the National Health Survey (Pesquisa Nacional de Saúde – PNS), a Brazilian household-based nationwide survey, which comprises 60,202 adults (aged 18 years or older). Depression was evaluated through the Patient Health Questionnaire-9 (PHQ-9). Prevalence Ratios and corresponding 95 % confidence intervals (95%CI) were calculated using Poisson regression. Results: The general prevalence of depression was 7.9 % (95 % CI 7.5 to 8.3). Among those with depression, 78.8 % did not receive any treatment, and 14.1 % received only pharmacotherapy. Multivariable analyses showed that being female, white, aged between 30 and 69 years, living in regions other than the North, having higher education and having multi-morbidities were independently associated with higher likelihood of access to any treatment. Conclusions: Most Brazilians with clinically relevant depressive symptoms are not receiving any treatment. Access to care is unequal, with the poor and those living in low resource areas having higher difficulties to access mental health care. Understanding these disparities is important for the provision of effective interventions aimed at reducing the prevalence of depression and inequities in access to mental health care. Keywords: Depression, Health surveys, PHQ-9, Mental health, Mental health service access Background Depression is one of the most important mental disorders, both due to its high prevalence worldwide and also because of the commonly chronic course of its presentation (leading to a high lifetime prevalence), with a significant burden for individuals’ lives and public health systems [1, 2]. Data from the Global Burden of Disease Study – 2010 showed that depression is the leading contributor, accounting for 2.5 % of Disability Adjusted Life Years (DALYs), and the second leading cause of disability, accounting for 8.2 % of Years Lived with * Correspondence: 1 Institute of Social Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil Full list of author information is available at the end of the article Disability (YLDs). Depression was also considered the main cause of 16 million suicide DALYs and almost 4 million ischaemic heart disease DALYs [3]. Effective treatment for depression includes antidepressant medications and psychotherapies, either alone or in combination [4]. However, a large proportion of those with depression do not receive any type of care. It is estimated that 35 to 50 % of individuals with severe depressive symptoms in high-income countries do not receive any treatment [5, 6]. Moreover, among those receiving care for depression, only about 20 % get effective treatment. In low- and middle-income countries the situation is even worse, with only 15 to 25 % of those with severe depressive symptoms receiving any treatment [5]. Lack of specialized human resources and adequate budgets © The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lopes et al. International Journal for Equity in Health (2016) 15:154 for mental health care account for a great deal of this huge deficiency [6]. This treatment gap is marked by social and geographical disparities, those who most need care, such as the poor and those living in where regions with limited mental health resources having greater difficulty receiving adequate care for depression. In Brazil, a 2013 population-based survey with a nationally representative sample, the National Health Survey (PNS), showed that the prevalence of major depression is higher among women, those living in urban areas, those with lower educational levels, and those with chronic conditions, such as hypertension and diabetes [7]. The data also showed that the lowest prevalence was observed in the Northern region, whereas the highest prevalence was found in the Southern region. In present study, we used the PNS data to examine the extent of the treatment gap for depression in Brazil and associated inequities. We aimed to: 1) estimate the proportion of Brazilians with clinically relevant depressive symptoms who have access to treatment; and 2) evaluate differences in access to treatment according to sociodemographic characteristics, geographical area and presence of multi-morbidity among those presenting clinically relevant depressive symptoms. Methods Study design and sample This study analyzed data from the National Health Survey (PNS), a household-based nationwide survey conducted by the Ministry of Health, in partnership with the Brazilian Institute of Geography and Statistics (IBGE), in 2013. The scope of the survey was to establish the health status and lifestyles of the population - as well as to examine aspects of access to and use of preventive and therapeutic services, continuity of care and health care financing. The survey sample was designed to allow for the estimation of indicators for Brazil and at different geographic levels, namely major regions, states, capitals, and metropolitan and rural areas. The sampling design was by clusters in three stages: In the first stage, census tracts or set of sectors were selected to from the primary sampling units (PSUs). In the second stage, households were randomly selected within each PSU. In the third stage, an adult resident (18 years old or older) was selected with equal probability among all adult residents in the household. Weighting factors were calculated for each of the three sampling units, considering the probabilities of selection and the non-response rate. For the selected resident, the weighting factor was calculated considering the weight for the corresponding household, the probability of selection of the resident, the a (...truncated)