FACTORS IMPACTING ON TREATMENT- SEEKING AND TREATMENT ENGAGEMENT IN ADOLESCENTS AND ADULTS WITH ANXIETY AND DEPRESSIVE DISORDERS

SUMMARY OF MAIN FINDINGS In Chapter 2 barriers and facilitators of treatment-seeking in adults with a DSM-IV anxiety and/or depressive disorder were investigated. The study used a qualitative design in order to deepen insight into these factors. Twenty-four participants were recruited from an outpatient mental health care department and the data were analysed using framework analysis. Our findings indicate that treatment-seeking reflects a complex interplay of multiple factors. The results yielded four main themes: individual aspects, personal social system, health care system and sociocultural background, with fourteen additional subthemes. Important individual aspects that hampered treatment-seeking were poor mental health literacy, stigma and negative attitudes (including coping style), and negative previous experiences. Facilitating individual aspects included increased disease burden, adequate mental health literacy, and positive beliefs towards and experiences with mental health care. The patient’s social surroundings and the general practitioner (GP) often facilitated treatment through recognizing symptoms and encouraging to seek help. However, social and cultural aspects – e.g., stigma – were in some cases hindering treatment-seeking. Lastly, organisational barriers delayed access to treatment, especially long waiting times and problems related to the referral to mental health care. Chapter 3 describes another qualitative study investigating barriers and facilitators of treatment-seeking, now focusing on adolescents and young adults aged 16-24 years with depressive symptoms (DSM-diagnosis not prerequisite) and with a special focus on facilitating aspects. Thirty- two participants were recruited from educational and mental health care institutions and through snowball sampling. The main findings included five themes, i.e., health literacy, attitudinal aspects, individual functioning and well-being, surroundings, and accessibility. Mental health illiteracy was an important hindrance to treatment-seeking. Adequate mental health literacy, if present, was facilitating. Attitudinal aspects (e.g., attitude towards treatment, stigma, and coping style) influenced willingness to seek treatment as well. Openness and a positive attitude towards professional care were identified as facilitators. Also, individual dysfunctioning and increased disease burden (i.e., poor school performance, physical symptoms and increased mental distress) were prompts to seek help. Furthermore, the adolescent’s social surroundings played a central role in the pathway to care. Recognition and encouragement from others were helpful. Contrarily, a negative judgment from others hindered treatment-seeking. Organisational barriers were also of relevance, with waiting time and referral issues being obstacles to timely access. Whenever young individuals had direct and easy access to care, this significantly enabled mental health care use. Chapter 4 embargo Chapter 5 embargo In Chapter 6, we systematically reviewed the literature on failure to respond to the same antidepressant after reinstatement, in patients with an initial response to that specific antidepressant. Ten studies (nine prospective studies and one retrospective chart review) published between 1989 and 2006 were included. This phenomenon was found in individuals with depression and dysthymia, obsessive-compulsive disorder or social phobia. The majority of studies regarded patients with depression or dysthymia. Failure to respond after reinstatement occurred in approximately 16.5% of patients with a broad range between the different studies (3.8 - 42.9%), and was described for monoamine oxidase inhibitors, tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and noradrenalin reuptake inhibitors (SNRIs). The quality of the included studies was low to moderate, e.g., no RCTs were found. These limitations hamper firm conclusions and emphasise the need for further research on this subject, as anxiety and depressive disorders are prevalent, a high number of patients use antidepressants and patients often relapse.