Original
Sociodemographic Variables, Symptomatic Severity, and Therapy Attendance: A Binary Regression Model
Celia Antuña-Camblor(1, María F. Rabito-Alcón(2 and Francisco Javier Rodríguez-Díaz(1
1) Department of Psychology, University of Oviedo, Oviedo, Spain
2) Department of Psychology, Open University of Madrid (UDIMA)
Ansiedad y Estrés, (2024), 30(3), 168-174
https://doi.org/10.5093/anyes2024a21
https://www.ansiedadyestres.es
Bibliography reference
INFO ARTICLE
Received 23 July 2024
Accepted 18 November 2024
Pub 21 December 2024
ABSTRACT
Background: Over time, the concept of health has evolved, focusing more on mental well-being. Despite this, pervasive prejudices remain to hinder therapy attendance. This study aimed to identify and assess factors influencing therapy attendance and the probability associated with non-attendance. Method: The sample comprised 753 participants (46.22% men, 53.78% women) aged 18-65 (M = 33.26; SD = 12.13). The evaluation was conducted online using an evaluation protocol that included an ad hoc sociodemographic questionnaire, the List of Brief Symptoms (LSB-50), and the Social Support Survey (MOS). Results: While sex and social support showed no significance, age, symptom severity, and family history of mental health problems emerged as relevant predictors, accounting for a 30.3% probability in therapy non-attendance prediction. Conclusions: With the variables indicated, the model explains approximately 30.3% of variability. However, it would be advisable to carry out studies at the national level that allow the conclusions to be extrapolated.
KEYWORDS
non-attendance
psychotherapy
sociodemographic
regression
Variables Sociodemográficas, Gravedad Sintomática y Asistencia a Terapia: Un Modelo de Regresión Binaria
Ansiedad y Estrés, (2024), 30(3), 168-174
https://doi.org/10.5093/anyes2024a21
https://www.ansiedadyestres.es
Bibliography reference
RESUMEN
Antecedentes: Con el tiempo, el concepto de salud ha evolucionado, centrándose más en el bienestar mental. A pesar de ello, persisten prejuicios que dificultan la asistencia a terapia. Este estudio pretendía identificar y evaluar los factores que influyen en la asistencia a terapia y conocer la probabilidad asociada a la no asistencia. Método: La muestra estuvo formada por 753 participantes (46,22% hombres, 53,78% mujeres) de entre 18 y 65 años (M = 33,26; DE = 12,13). La evaluación se realizó online utilizando un protocolo de evaluación que incluía un cuestionario sociodemográfico ad hoc, la Lista de Síntomas Breves (LSB-50) y la Encuesta de Apoyo Social (MOS). Resultados: Mientras que el sexo y el apoyo social no mostraron significación, la edad, la gravedad de los síntomas y los antecedentes familiares de salud mental emergieron como predictores relevantes, representando un 30,3% de probabilidad en la predicción de la no asistencia a terapia. Conclusiones: Con las variables indicadas, el modelo explica aproximadamente el 30,3% de la variabilidad. Sin embargo, sería recomendable realizar estudios a nivel nacional que permitan extrapolar las conclusiones.
PALABRAS CLAVE
inasistencia
psicoterapia
sociodemográfico
regresión
Introduction
Throughout history, the notion of health has undergone significant transformations that have led to a more holistic understanding of well-being. In this context, the World Health Organization (WHO) expanded the definition of health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1948). Despite this global and comprehensive perspective, mental health, a crucial component, has for decades been relegated to the background despite its vital importance.
Although traditional medical care has largely prioritized physical health (Rodelo Valle & Garay Núñez, 2020), the high prevalence of common mental disorders in Primary Care consultations in Spain is surprising (Bobes et al., 2013; Henares et al., 2020; Roca et al., 2009). Specifically, about 30–50% of Spanish Primary Care users suffer mental health problems, specifically emotional disorders (Anmella et al., 2024; Spanish Ministry of Health, 2024). This phenomenon is puzzling, especially considering the availability of specialized mental health professionals. Despite the abundance of professionals, most of these individuals are attended by family physicians rather than specialized personnel (Kovess-Masfety et al., 2007). The paradox lies in the fact that, despite ample evidence of the efficacy of psychotherapy in various psychopathological disorders and globally (Fonseca, 2021; Ruiz-Rodríguez et al., 2017) , traditional medical care continues to play a predominant role in the management of mental health problems.
These data might suggest that people suffering from a mental disorder tend to seek psychological treatment, whether in the public or private system. However, the reality differs markedly from this assumption. For example, a study published by Terlizzi and Norris (2021) indicates that in the United States, only 20.3% of adults had received any mental health treatment in the last 12 months, which may lead the almost 80% remaining to a chronification and aggravation of the problem (Swift & Greenberg, 2012) , with not only personal but also economic and social repercussions (Ruiz-Rodríguez et al., 2017) . However, in recent years, there has been a significant increase in the use of psychotropic drugs in Spain and the use of anxiolytics and antidepressants (Spanish Ministry of Health, 2024; Spanish Subdirectorate General of Health Information, 2021). The consumption of antidepressants and hypnotics and sedatives increased by 18.1% and 6.9% respectively since 2019, with Spain being the third country with the highest consumption of psychotropic drugs in the European Union (Spanish Ministry of Health, 2024)
In the specific context of the Principality of Asturias, a region that stands out for its high frequency of medical prescription of antidepressants (13.2%) and triples the national rate of tranquillizer use (Henares et al., 2020) and a population with aging demographic characteristics (Bobes et al., 2013), the highest national frequency can be seen in terms of the existence of mental health problems. This region exhibits the highest frequency nationally in terms of the prevalence of mental health problems. Thus, 25.9% of the population has received at least one diagnosis of psychopathological disorder, with a higher incidence in women (32.3%) compared to men (16.6%) (Henares et al., 2020) . Interestingly, despite this high prevalence of mental health problems, a worrying fact emerges when looking at help-seeking behavior in the Asturian population. According to the study (Bobes et al., 2013), only a quarter of people in the general population who experienced a mental disorder in the last year sought care in mental health services. This discrepancy between the prevalence of mental disorders and help-seeking suggests a significant gap in the utilization of mental health services in this region.
Additionally, it is worth noting that even though 38.3% of the population reports having a perception of poor health (Henares et al., 2020) . Thus, the proportion of those who seek care in mental health services remains considerably low. This phenomenon raises questions about perceived or real barriers that could be influencing people's decision not to seek treatment despite the prevalence and negative perception of mental health in the region.
Although people's reluctance to seek help for mental disorders is a complex and multifaceted phenomenon, research has identified significant factors that contribute to this reluctance. One of the key aspects that has been explored in this context is the persistence of stigma (Dickerson et al., 2002) and discrimination (Thornicroft et al., 2009) associated with mental health. Despite notable advances, it is found that even though with the use of new technologies to perform therapy, stigma has slightly decreased (Chen et al., 2020), it remains a current barrier for many people (Bharadwaj et al., 2017; Torales et al., 2023). Another crucial factor that could be contributing to the reluctance to seek psychological help is the bureaucratic process and paperwork associated with care in the National Health System.
Activating a psychological care protocol involves starting with an interview with the Primary Care physician. This is followed by coordination with the Mental Health Center to assess the need for assistance and, finally, to reach the first consultation with the mental health service, specifically with the psychiatrist (Tejedo, 2022). Although designed to ensure comprehensive care, this process could be perceived as complicated or discouraging, which could affect affecting people's willingness to seek help. In addition, the fact that the first of the consultations is with the psychiatrist may act as a deterrent for numerous individuals who are considering seeking assistance in this area. The insufficient ratio of psychologists per inhabitant, which does not conform to European standards, also emerges as a considerable challenge in access to psychological care (Fernández-García, 2021). The shortage of mental health professionals can be associated with long waiting times. It can limit the availability of specialized services, thus exacerbating barriers that prevent people from accessing the help they need.
However, despite the diversity of factors that may influence the decision to seek psychological help, it is essential to deepen the analysis of these variables. Several studies have highlighted the relevance of age in this process, suggesting that, during adulthood, older people tend to seek psychological assistance more frequently (Fekih-Romdhane et al., 2023; Swift & Greenberg, 2012). This phenomenon manifests as a significant change in the behavior of the elderly, who, according to research, show a greater reluctance to request interventions of this type (Conwell et al., 2012). In addition, sex has also been related to psychological help-seeking, as men appear to be more reluctant to seek therapy (Bretz et al., 2019; Fekih-Romdhane et al., 2023; Judd et al., 2008; Kim & Lee, 2022).
In terms of socioeconomic status, empirical evidence indicates that people of higher socioeconomic status tend to seek less help from mental health professionals (Packness et al., 2017; Swift & Greenberg, 2012). On the other hand, regarding the history of mental illness, research has yielded mixed results, with some studies suggesting that this history increases the likelihood of seeking help (Kim & Lee, 2022), while others have found an opposite effect, i.e., that the presence of a family psychological or psychiatric history decreases access to therapy (Fekih-Romdhane et al., 2023). Therefore, in this variable, it can be interpreted that there may be a detection of symptoms or perhaps due to a normalization of symptoms.
If we consider symptom severity, it seems that the relationship is directly proportional between symptom intensity and seeking professional help (Sum et al., 2023). Both symptom severity and psychotherapy attendance have been found to be related to social support. Individuals with low social support are more likely to manifest mental health problems (Backhaus et al., 2023; Seymour-Smith et al., 2021) and attend therapy less compared to those who enjoy greater social support (Bretz et al., 2019). Finally, those experiencing more intense psychological symptoms are motivated to seek professional help, recognizing the need for specialized interventions to improve their mental well-being. This is reflected by previous studies demonstrating the existence of a positive correlation between psychopathological severity and psychological treatment-seeking (Blais et al., 2014; Dean et al., 2018; Knowles et al., 2019).
The current study
Currently, sociodemographic variables and symptom severity as a predictor of therapy attendance have not been investigated. The present study attempts to address this gap. Specifically, given the importance of providing a health service to individuals and detecting difficulties, this research study aims to address the dynamics surrounding individuals seeking psychological care comprehensively. The hypotheses were that older women belonging to lower socioeconomic classes, with a family history of mental health problems, and with strong social support would demonstrate a greater propensity to seek psychological help.
Methods
Participants
A cross-sectional study was conducted between August 2022 and January 2023. Data were collected using an online methodology through the Survey Monkey platform. The average time to complete the evaluation was approximately 30 minutes. Due to the study's observational characteristics, the only exclusion criterion was under 18 years. This study was submitted for approval by the Research Ethics Committee of the Principality of Asturias under the number 2022.193, thus guaranteeing compliance with ethical standards and integrity in the conduct of the study.
At the end of the data collection period, 935 adults had started the survey, but only 753 had completed it correctly (80.53% of the total reached). Participants who did not complete all the required questionnaires or did not meet the inclusion criteria (adults habitually resident in the Principality of Asturias) were excluded. The final sample consisted of 753 subjects (46.22 % male, 53.78% female) aged between 18 and 65 (M = 33.26, SD = 12.13). They participated voluntarily in the research and provided informed consent. The characteristics of the sample appear in Table 1.
-- Insert Table 1 --
Instruments
Ad-Hoc Sociodemographic Questionnaire. The ad-hoc sociodemographic questionnaire designed for this study comprises a series of key questions that seek to collect comprehensive information on various social and demographic aspects of the participants' lives. Categories assessed include age, sex, marital status, family history of mental health problems, attendance to therapy in the last 12 months, and socioeconomic status The participants reported one item for each variable.
Global Symptomatic Severity Index (IRPsi) of Brief Symptom Checklist (LSB-50) (de Rivera et al., 2012). The analysis of symptomatic severity is carried out using the Global Symptomatic Severity Index, one of the indexes of the Brief Symptom Checklist (LSB-50), a validated and recognized tool in psychological research (de Rivera et al., 2012). This index, which has been shown to possess high levels of reliability (a = .96) (de Rivera et al., 2012), breaks down and assesses the presence and magnitude of a wide variety of symptoms, providing a comprehensive measure of the degree of global psychopathological involvement in patients. This study's consistency was high (a = .96, O = .91).
The Social Support Survey (MOS) (Spanish version: de la Revilla Ahumada et al., 2005; Sherbourne & Stewart, 1991). This instrument consists of 20 items on a five-point Likert scale (from "never" = 1 to "always" = 5) that measure the degree to which the subject perceives that he/she can count on the support of people in different contexts. It provides an overall index and four subscales measuring its emotional, material, affective, and positive social interaction components. As in its assessment, in which the levels of internal consistency have been shown to be high (de la Revilla Ahumada et al., 2005). This study's internal consistency was high (a = .96, O = .94).
Data analysis
The IBM-SPSS (v.27) data analysis software was used to perform the statistical analyses, and the OMEGA macro was used to calculate the omega coefficient (Hayes & Coutts, 2020). First, basic descriptive statistics were calculated for the sample and the variables involved in the study. Because only three participants reported low socioeconomic status and two reported high socioeconomic status, the variables were recoded into lower-middle socioeconomic status and upper-middle socioeconomic status.
This was followed by an analysis of the differences between the therapy attendance and non-attendance groups. The Chi-square statistic was used for dichotomous variables (sex, marital status grouped into with a partner and without a partner, and socioeconomic levels). For quantitative variables, it was found that the variables do not meet the assumption of normality (p < .05), so the Mann Whitney U test was used to compare the two independent samples.
A multivariate backward stepwise logistic regression was performed using the likelihood ratio (LR) criterion for the dependent variable (attendance to psychological therapy) and the independent variables (age, symptom severity index, family history of mental health problems, marital status, socioeconomic level, and social support). This multivariate binary logistic regression selected variables with a p-value equal to or less than .05 in the Wald test. The variables were coded in a specific way: "attends therapy" = 0; "does not attend therapy" = 1; and the dummy variables were chosen automatically by the SPSS 27.0 program. Subsequently, the percentage of variance explained by the model was calculated, as well as the ratio that facilitates the association of the probability of patients attending or not attending therapy.
Results
Firstly, 40.73% of the participants had attended psychological therapy in the last 12 months. Regarding the differences between the two groups (attending therapy vs. not attending therapy), differences were found in terms of age, social support, and symptomatic severity (Table 2).
-- Insert Table 2 --
In the first phase of analysis, we evaluate the adequacy of the data collection model. Thus, the Hosmer-Lemeshow test, which examines the model's fit, has insufficient evidence to reject the null hypothesis (p = .950) so that the model is adequate. This result supports the fit of the model to the observed data. Coincidentally, omnibus tests of model coefficients (p < .001) support the robustness of the overall model.
In terms of variance explained, the Nagelkerke value, .303, reveals that the model explains approximately 30.3% of the variability in the variable "does not attend therapy." Table 3 presents the coefficients associated with the variables included in the final model, according to the last step of the analysis. These coefficients provide valuable information on the relative contribution of each variable in explaining the dependent variable. This level of detail facilitates a more precise interpretation of how each variable influences the probability of not attending therapy, thus providing essential information for understanding the factors underlying the observed behavior.
-- Insert Table 3 --
These results support the robustness and usefulness of the model developed in this study for analyzing and understanding the variable of interest. Only three of the variables examined (age, severity of symptomatology, and family history of mental health problems) have significant weight, while sex (p = .08), socioeconomic level (p = .18), the MOS score (p = .94) and the MOS subscales scores (namely, emotion support (p = .82), instrumental support (p = .45), positive social interaction (p = .85) and affective support (p = .29)) were not significant in the model.
Therefore, the probability of not attending therapy is estimated at:
The probability of attending therapy is estimated at:
Discussion
The concept of health has undoubtedly undergone an evolution that includes the state of well-being of individuals. Despite the notable weight that physical health continues to have, today, we find a high prevalence of mental disorders, which underlines the need to recognize and treat them as health problems. Moreover, despite the existence of mental health professionals, most people with mental disorders are seen by family physicians rather than specialists. This discrepancy between the high prevalence of mental disorders and the predominant allocation of care by family physicians highlights the need for a critical review of current practices. Psychotherapy, being an effective tool and supported by scientific evidence, should play a more central role in addressing emotional and psychological difficulties in the Primary Care setting. However, the gap between what is desired and reality suggests a problem of access or referral to specialized services. It is crucial to consider accessibility and public awareness of the efficacy of psychotherapy. Despite the demonstrated advantages, there may be a lack of information among patients and healthcare professionals about the relevance and benefits of psychotherapy compared with more traditional approaches. Continuing education and awareness campaigns could be vital in changing perceptions and encouraging a transition to a more holistic approach to care.
This study was designed to address the social factors that influence help-seeking, as other studies had previously done. However, the results have not been replicated. Although sex seems to be one of the relevant factors in help-seeking (Fekih-Romdhane et al., 2023; Judd et al., 2008; Kim & Lee, 2022), in this study it has not been shown to have a significant weight. This may be due to the type of sample used since, the men who responded to the questionnaire may be more committed to mental health or may even be receiving psychological treatment themselves or their relatives. Differences were also found in terms of socioeconomic status, even though other studies had shown that people of higher socioeconomic levels tend to seek less help from mental health professionals (Packness et al., 2017; Swift & Greenberg, 2012), whereas in this study it was not a significant variable associated with not seeking help. This could be because people tend to score at medium levels, as it is a self-reported question
In terms of age, it has been shown to be significant. In this sense, as in previous studies (Fekih-Romdhane et al., 2023; Swift & Greenberg, 2012), younger people tend to ask for less help. This could be because older people may have been suffering from symptoms for several years, with a chronification of symptoms over time that leads them to ask for more help, or due to the low awareness of illness that younger people present. Thus, the illusion of invulnerability, which entails the belief that adverse events will not affect them personally, has been frequently described in younger people (Rodin & Salovey, 1989). This bias may influence reluctance to seek therapeutic help because when young people perceive that they are exempt from facing emotional or mental difficulties, they are likely to underestimate the importance of therapeutic intervention and, consequently, not consider the need to attend therapy. If we consider that young people's reluctance not to attend therapy is due to low illness awareness, it could coincide with data indicating that the presence of family history is conducive to not attending therapy, perhaps because of a normalization of symptoms, which goes against previous studies (Kim & Lee, 2022). It may also be that young people wish to test their mental health problem-solving skills by developing self-efficacy. However, the results are consistent with previous studies regarding symptom severity (Sum et al., 2023), perhaps because the more severe the symptoms, the more the importance of resolving them is known, coinciding with their chronification or with the comorbidity of the diagnoses.
This study should be analyzed regarding its limitations. Firstly, the study employed a cross-sectional design, capturing data at a single point in time. Secondly, the reliance on self-report measures, such as questionnaires, introduces the possibility of response bias and social desirability. Participants may underreport or overreport certain behaviors due to perceived societal norms or personal biases, impacting the accuracy of the data. Thirdly, the sample that has agreed to participate in the research may be more aware of mental health and, therefore, may be predisposed to seek psychological therapy. Furthermore, the sample used corresponds to an autonomous community, so it needs to be more generalizable. A key limitation of the study lies in its possible omission of interaction effects between variables. Although the regression model identifies certain variables, such as age, level of distress, and family history, as significant predictors of whether to attend therapy, it may overlook how these variables interact with each other. In this sense, it has been seen that there are differences between the groups in terms of social support, which could imply that interactions are relevant. This could mean that, for example, the effect of social support might only be relevant in individuals experiencing high levels of distress, or marital status might influence therapy attendance differently depending on age or family history. Finally, the focus of the study was limited to sociodemographic variables and symptomatological distress due to it was the aim of the study. However, other factors, such as prejudice, stigma, discrimination, or the bureaucratic process when seeking help, may affect therapy attendance. Although these variables have been left out of our study object, future research lines could include them.
However, despite these limitations, the results offer valuable insights for clinical practice. In this context, the importance of establishing a meaningful therapeutic relationship and building a solid therapeutic alliance with all patients is emphasized so that they can see it as a valuable process and pass it on to their social and family circle once they have decided to initiate therapy. Conversely, negative perceptions of therapy can be a major obstacle, which can lead to premature discontinuation of treatment and decrease the future likelihood that these individuals will seek therapy. In addition, it is essential to consider the relevance of working to reduce the social stigma associated with mental health problems. Addressing and reducing stigma can play a key role in facilitating access to mental health services, fostering a more conducive environment for people to recognize the importance of seeking help, and overcoming psychosocial barriers that may be associated with the stigmatization of mental health problems. To this end, psychoeducational interventions can be carried out aimed, according to the results of this study, at younger people so that they can attend mental health services, avoiding the chronification or comorbidity of psychological symptomatology.
In summary, despite the limitations identified, the practical implications derived from this study highlight the need for sensitive and personalized therapeutic approaches focused on reducing the barriers that hinder help-seeking. This study opens up an exciting field within psychotherapy since it has been seen that many people do not seek psychological treatment but instead go to Primary Care physicians. Replicating this study with a national sample could help us improve psychological care or urge the inclusion of general health psychologists in public health care, as some autonomous communities do, to carry out preventive and mental health promotion tasks. These considerations can significantly improve the effectiveness of interventions and contribute to a more holistic approach to mental health in the community. The conclusions derived from the present study shed light on crucial sociodemographic factors that influence the decision to seek psychological help. However, it is essential to note that, due to the specificity of the participants within the Principality of Asturias, generalization of the results to other populations may require caution. This study shows that age, symptoms' severity, and family history of mental health problems influence whether patients attend therapy. In this sense, the probability of not attending therapy decreases by -0.019 for each additional year the patient completes as the severity of symptoms intensifies and with the presence of a family history of mental health problems.
Conflicts of interest
The authors report there are no competing interests to declare.
Data Availability Statement
The study data are only available upon request. The name(s) of the contact person(s) to request data are available upon request to all interested researchers. Legal and ethical restrictions make data available upon request and are in accordance with the nature of the data collection.
Data are available from the promoter (Spain) for researchers who meet the criteria for access to confidential data. Interested researchers should contact to author of correspondence.
Ethics approval statement
This study was submitted for approval by the Research Ethics Committee of the Principality of Asturias under the number 2022.193, thus guaranteeing compliance with ethical standards and integrity in the conduct of the study.
Patient consent statement
The participants voluntarily in the research and provided informed consent
References
Anmella, G., Primé-Tous, M., Segú, X., Solanes, A., Ruíz, V., Martín-Villalba, I., Morilla, I., Also-Fontanet, A., Sant, E., Murgui, S., Sans-Corrales, M., Murru, A., Zahn, R., Young, A. H., Vicens, V., Viñas-Bardolet, C., Martínez-Cerdá, J. F., Blanch, J., Radua, J., … Hidalgo-Mazzei, D. (2024). PRimary carE digital Support ToOl in mental health (PRESTO): Design, development and study protocols. Spanish Journal of Psychiatry and Mental Health, 17(2), 114–125. https://doi.org/10.1016/j.rpsm.2021.04.003
Backhaus, I., Fitri, M., Esfahani, M., Ngo, H. T., Lin, L., Yamanaka, A., Alhumaid, M. M., Qin, L., Khan, A., Fadzullah, N. ’Ashikin, & Khoo, S. (2023). Mental Health, Loneliness, and Social Support Among Undergraduate Students: A Multinational Study in Asia. Asia Pacific Journal of Public Health, 35(4), 244–250. https://doi.org/10.1177/10105395231172311
Bharadwaj, P., Pai, M. M., & Suziedelyte, A. (2017). Mental health stigma. Economics Letters, 159, 57–60. https://doi.org/10.1016/j.econlet.2017.06.028
Blais, R. K., Hoerster, K. D., Malte, C., Hunt, S., & Jakupcak, M. (2014). Unique PTSD Clusters Predict Intention to Seek Mental Health Care and Subsequent Utilization in US Veterans with PTSD Symptoms. Journal of Traumatic Stress, 27(2), 168–174. https://doi.org/10.1002/jts.21898
Bobes, J., Iglesias García, C., García-Portilla González, M. P., Bascarán, M. T., Jiménez Treviño, L., Pelayo-Terán, J. M., Rodríguez Revuelta, J., Sánchez Lasheras, F., & Sáiz Martínez, P. (2013). Evolución de la prevalencia administrativa de los trastornos mentales durante 13 años en Asturias (norte de España). Revista de Psiquiatría y Salud Mental, 6(2), 60–66. https://doi.org/10.1016/j.rpsm.2012.10.002
Bretz, J., Sahin, D., Brandl, E., & Schouler-Ocak, M. (2019). Kulturabhängigkeit der Einstellung gegenüber psychotherapeutischer Behandlung bei Türkeistämmigen und Personen ohne Migrationshintergrund. PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie, 69(5), 176–181. https://doi.org/10.1055/a-0583-1093
Chen, J. A., Chung, W.-J., Young, S. K., Tuttle, M. C., Collins, M. B., Darghouth, S. L., Longley, R., Levy, R., Razafsha, M., Kerner, J. C., Wozniak, J., & Huffman, J. C. (2020). COVID-19 and telepsychiatry: Early outpatient experiences and implications for the future. General Hospital Psychiatry, 66, 89–95. https://doi.org/10.1016/j.genhosppsych.2020.07.002
Conwell, Y., van Orden, K., & Caine, E. D. (2012). Suicidio en ancianos. Psiquiatría Biológica, 19(4), 127–136. https://doi.org/10.1016/j.psiq.2012.09.003
de la Revilla Ahumada, L., Luna del Castillo, J., Bailón Muñoz, E., & Medina Moruno, I. (2005). Validación del cuestionario MOS de apoyo social en Atención Primaria. Medicina de Familia, 6, 10–18.
de Rivera, J. L. G., de Rivera, L., & Abuín, M. (2012). LSB-50: Listado de síntomas breve. Manual. TEA Ediciones.
Dean, K. E., Long, A. C. J., Matthews, R. A., & Buckner, J. D. (2018). Willingness to Seek Treatment Among Black Students With Anxiety or Depression: The Synergistic Effect of Sociocultural Factors With Symptom Severity and Intolerance of Uncertainty. Behavior Therapy, 49(5), 691–701. https://doi.org/10.1016/j.beth.2017.12.008
Dickerson, F. B., Sommerville, J., Origoni, A. E., Ringel, N. B., & Parente, F. (2002). Experiences of Stigma Among Outpatients With Schizophrenia. Schizophrenia Bulletin, 28(1), 143–155. https://doi.org/10.1093/oxfordjournals.schbul.a006917
Fekih-Romdhane, F., Jahrami, H., Stambouli, M., Alhuwailah, A., Helmy, M., Shuwiekh, H. A. M., Lemine, C. M. fadel M., Radwan, E., Saquib, J., Saquib, N., Fawaz, M., Zarrouq, B., Naser, A. Y., Obeid, S., Hallit, S., Saleh, M., Haider, S., Daher-Nashif, S., Miloud, L., … Cheour, M. (2023). Cross-cultural comparison of mental illness stigma and help-seeking attitudes: a multinational population-based study from 16 Arab countries and 10,036 individuals. Social Psychiatry and Psychiatric Epidemiology, 58(4), 641–656. https://doi.org/10.1007/s00127-022-02403-x
Fernández-García, X. (2021). Situación de la psicología clínica en el Sistema Nacional de Salud (SNS) y perspectivas de crecimiento. Ansiedad y Estrés, 27(1), 31–40. https://doi.org/10.5093/anyes2021a5
Fonseca, E. (2021). Manual de tratamientos psicológicos (E. Fonseca, Ed.; 1a Edición). Pirámide.
Hayes, A. F., & Coutts, J. J. (2020). Use Omega Rather than Cronbach’s Alpha for Estimating Reliability. But…. Communication Methods and Measures, 14(1), 1–24. https://doi.org/10.1080/19312458.2020.1718629
Henares, J., Ruiz-Pérez, I., & Sordo, L. (2020). Salud mental en España y diferencias por sexo y por comunidades autónomas. Gaceta Sanitaria, 34(2), 114–119. https://doi.org/10.1016/j.gaceta.2019.03.002
Judd, F., Komiti, A., & Jackson, H. (2008). How Does Being Female Assist Help-Seeking for Mental Health Problems? Australian & New Zealand Journal of Psychiatry, 42(1), 24–29. https://doi.org/10.1080/00048670701732681
Kim, S. B., & Lee, Y. J. (2022). Factors Associated with Mental Health Help-Seeking Among Asian Americans: a Systematic Review. Journal of Racial and Ethnic Health Disparities, 9(4), 1276–1297. https://doi.org/10.1007/s40615-021-01068-7
Knowles, K. A., Sripada, R. K., Defever, M., & Rauch, S. A. M. (2019). Comorbid mood and anxiety disorders and severity of posttraumatic stress disorder symptoms in treatment-seeking veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 11(4), 451–458. https://doi.org/10.1037/tra0000383
Kovess-Masfety, V., Alonso, J., Brugha, T. S., Angermeyer, M. C., Haro, J. M., & Sevilla-Dedieu, C. (2007). Differences in Lifetime Use of Services for Mental Health Problems in Six European Countries. Psychiatric Services, 58(2), 213–220. https://doi.org/10.1176/ps.2007.58.2.213
Packness, A., Waldorff, F. B., Christensen, R. dePont, Hastrup, L. H., Simonsen, E., Vestergaard, M., & Halling, A. (2017). Impact of socioeconomic position and distance on mental health care utilization: a nationwide Danish follow-up study. Social Psychiatry and Psychiatric Epidemiology, 52(11), 1405–1413. https://doi.org/10.1007/s00127-017-1437-2
Roca, M., Gili, M., Garcia-Garcia, M., Salva, J., Vives, M., Garcia Campayo, J., & Comas, A. (2009). Prevalence and comorbidity of common mental disorders in primary care. Journal of Affective Disorders, 119(1–3), 52–58. https://doi.org/10.1016/j.jad.2009.03.014
Rodelo Valle, C., & Garay Núñez, J. R. (2020). Representaciones sociales de la salud mental y de los trastornos mentales en estudiantes universitarios de enfermería. Dilemas Contemporáneos: Educación, Política y Valores. https://doi.org/10.46377/dilemas.v8i.2483
Rodin, J., & Salovey, P. (1989). Health Psychology. Annual Review of Psychology, 40(1), 533–579. https://doi.org/10.1146/annurev.ps.40.020189.002533
Ruiz-Rodríguez, P., Cano-Vindel, A., Muñoz Navarro, R., Medrano, L., Moriana, J. A., Buiza Aguado, C., Jiménez Cabré, G., & González-Blanch, C. (2017). Impacto económico y carga de los trastornos mentales comunes en España: una revisión sistemática y crítica. Ansiedad y Estrés, 23(2–3), 118–123. https://doi.org/10.1016/j.anyes.2017.10.003
Seymour-Smith, M., Cruwys, T., & Haslam, S. A. (2021). More to lose? Longitudinal evidence that women whose social support declines following childbirth are at increased risk of depression. Australian and New Zealand Journal of Public Health, 45(4), 338–343. https://doi.org/10.1111/1753-6405.13099
Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science & Medicine, 32(6), 705–714. https://doi.org/10.1016/0277-9536(91)90150-B
Spanish Ministry of Health. (2024). National Health System Annual Report [Informe Anual del Sistema Nacional de Salud]. https://www.sanidad.gob.es/estadEstudios/estadisticas/sisInfSanSNS/tablasEstadisticas/InfAnualSNS2023/INFORME_ANUAL_2023.pdf
Spanish Subdirectorate General of Health Information. (2021). Mental health in data: prevalence of health problems and consumption of psychotropic and related drugs from primary care clinical records. BDCAP Series 2 [Salud mental en datos: prevalencia de los problemas de salud y consumo de psicofármacos y fármacos relacionados a partir de registros clínicos de atención primaria. BDCAP Series 2]. https://www.sanidad.gob.es/estadEstudios/estadisticas/estadisticas/estMinisterio/SIAP/Salud_mental_datos.pdf
Sum, M. Y., Chan, S. K. W., Tsui, H. K. H., & Wong, G. H. Y. (2023). Stigma towards mental illness, resilience, and help-seeking behaviours in undergraduate students in Hong Kong. Early Intervention in Psychiatry. https://doi.org/10.1111/eip.13455
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547–559. https://doi.org/10.1037/a0028226
Tejedo, A. (2022). El contexto de la atención psicológica a nivel ambulatorio en la red de salud mental pública catalana. Norte de Salud Mental, 18(67), 30–44.
Terlizzi, E. P., & Norris, T. (2021). Mental Health Treatment Among Adults: United States, 2020.
Thornicroft, G., Brohan, E., Rose, D., Sartorius, N., & Leese, M. (2009). Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet, 373(9661), 408–415. https://doi.org/10.1016/S0140-6736(08)61817-6
Torales, J., Aveiro-Róbalo, T. R., Ríos-González, C., Barrios, I., Almirón-Santacruz, J., González-Urbieta, I., Caycho-Rodríguez, T., Castaldelli-Maia, J. M., & Ventriglio, A. (2023). Discrimination, stigma and mental health: what’s next? International Review of Psychiatry, 35(3–4), 242–250. https://doi.org/10.1080/09540261.2023.2186218
World Health Organization. (1948). Summary Reports on Proceedings Minutes and Final Acts of the International Health Conference held in New York from 19 June to 22 July 1946. . https://apps.who.int/iris/handle/10665/85573