Health-related quality of life in primary care patients with recognized and unrecognized mood and anxiety disorders

OBJECTIVE: Primary care providers have been criticized for underrecognizing and undertreating mental health disorders. This criticism assumes patients with recognized disorders and those with unrecognized disorders suffer the same burden of illness. This study describes differences in health-related quality of life (HRQOL) in patients with recognized and unrecognized mood and anxiety disorders in a primary care setting. METHODS: A probability sample of 500 adult ambulatory patients from a university-based, family practice clinic, completed the PRIME-MD mood and anxiety disorder modules and the SF-36 Health Survey. Computerized patient records were reviewed retrospectively to determine recognition of mood and anxiety disorders. The Mental Health (MCS) and Physical Health (PCS) Component Summary scales of the SF-36 served as the primary outcome measures. RESULTS: Sub-threshold mood and anxiety disorders were less likely to be recognized by physicians than disorders meeting DSM-III-R criteria. Recognized mood disorders were associated with a significant decrement in MCS scores (poorer HRQOL) compared with unrecognized disorders. In contrast, recognized mood disorders demonstrated slightly higher PCS scores. Recognized and unrecognized mood disorders differed significant ly in physical functioning, vitality, social functioning, role functioning related to emotional state, and mental health. Recognition of anxiety disorders was not related to HRQOL. Conclusions: Patients with mental health disorders that have been recognized by their health providers appear to suffer from poorer HRQOL than patients whose disorders have not been recognized. This relationship, though, is only apparent for mood disorders. Poorer physical functioning may mask less severe emotional symptoms in mood disorders; profound emotional symptoms make recognition easier.     

Disability in Te Rau Hinengaro: the New Zealand Mental Health Survey

OBJECTIVE: To show the disability associated with 1 month mental disorders and chronic physical conditions for the New Zealand population, controlling for comorbidity, age and sex. METHOD: A nationally representative face-to-face household survey was carried out from October 2003 to December 2004 with 12,992 participants aged 16 years and over, achieving a response rate of 73.3%. Mental disorders were measured with the World Mental Health (WMH) Survey Initiative version of the Composite International Diagnostic Interview (CIDI 3.0). Disability was measured with the WMH Survey Initiative version of the World Health Organization Disability Assessment Schedule (WMH WHO-DAS) in the long-form subsample (n = 7435). Outcomes include five WMH WHO-DAS domain scores for those with 1 month mental disorders and with chronic physical conditions. RESULTS: Mood disorders were associated with more disability than anxiety or substance use disorders. Experiencing multiple mental disorders was associated with substantial role impairment. Mental disorders and chronic physical conditions were associated with similar degrees of disability on average. The combination of mental and physical disorders had additive effects on associated disability. CONCLUSIONS: Mood disorders are disabling. The investigation of disability in relation to 1 month rather than 12 month disorders is likely to provide a clearer indication of the disability associated with mood disorders. Although some researchers have queried whether negative mood can lead to 'over-reporting' of disability, recent conceptualizations of disability provide a perspective which may ease such concerns. Comorbidity, of mental disorders or of mental and physical disorders, is disabling.     

Moroccan national study on prevalence of mental disorders: a community‐based epidemiological study

Objective: The main objective of this study was to assess the prevalence of common mental disorders in the Moroccan general population. Method: On a systematic representative randomized sample, the Moroccan Arabic version of the Mini International Neuropsychiatric Interview (MINI) was used to assess the prevalence of mood, anxiety, substance, and alcohol abuse disorders. Results: Among 5498 subjects interviewed, 40.1% had at least one current mental disorder. Current major depressive disorder was the most common (26.5%), and at least one anxiety disorder was found in 37% of the sample. Mental disorders were more frequent among female, urban, divorced, and unemployed subjects. Conclusion: Mental disorders are common in the Moroccan general population, particularly mood and anxiety disorders.     

Mental health service use by older adults: the role of chronic pain.

OBJECTIVE: Mental health disorders commonly co-occur in patients with chronic pain, but little is known about the role of chronic pain in mental health service use. In this study, the authors explored the role of chronic pain in mental health service use by adults according to age group. METHOD: The authors conducted a cross-sectional analysis of survey data from the second wave of the Health Care for Communities telephone survey collected in 2000-2001. Participants consisted of U.S. civilian adults (N = 6629) from randomly selected U.S. households. Common mental disorders were assessed using the short-form versions of the World Health Organization's Composite International Diagnostic Interview. Chronic pain conditions and mental health services received were identified by self-report. Physical and mental functioning was assessed using the Short Form-12. RESULTS: Adults older than age 60 had higher rates of chronic pain and lower rates of mental health service use compared with those aged 18-60 years. In multiple logistic regression models, an interaction effect was found between age and chronic pain (odds ratio: 3.0 [1.1-8.0]) with chronic pain significantly increasing the odds of any mental health care in the past year in adults older than 60 years of age. CONCLUSIONS: Chronic pain increases the likelihood of mental health service use among older adults. Chronic pain may facilitate the presentation of distress in medical settings for these adults.     

The relationship between anxiety disorders and physical disorders in the U.S. National Comorbidity Survey

Although depression has clearly been shown to be associated with physical disorders, few studies have examined whether anxiety disorders are independently associated with medical conditions after adjusting for comorbid mental disorders. We examined the relationship between anxiety disorders and a wide range of physical disorders in a nationally representative sample. Data came from the National Comorbidity Survey (N=5,877, range=age 15-54 years, response rate=82.4%). The Composite International Diagnostic Interview [Kessler et al., 1998] was used to make DSM-III-R [American Psychiatric Association, 1987] mental disorder diagnoses. Physical disorders were assessed based on a list of several conditions shown to respondents. All analyses utilized multiple logistic regression to examine the relationship between past-year anxiety disorder diagnosis and past-year chronic physical disorder. Anxiety disorders were positively associated with physical disorders even after adjusting for mood disorders, substance-use disorders, and sociodemographics. Among respondents with one or more physical disorders, a comorbid anxiety disorder diagnosis was associated with an increased likelihood of disability even after adjusting for severity of pain, comorbid mood, and substance use disorders. Among specific anxiety disorders, posttraumatic stress disorder, panic attacks, and agoraphobia were more likely to be associated with specific physical disorders than generalized anxiety disorder, social phobia, or simple phobia. There is a strong and unique association between anxiety disorders and physical disorders. Clinically, the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.     

Comorbid physical health conditions and anxiety disorders: a population-based exploration of prevalence and health outcomes among older adults

ObjectiveThe primary objectives of this study were to examine the likelihood of anxiety disorders among respondents with common physical health conditions and to explore the associations between this comorbidity and older adults' perceived mental and physical health.MethodThe sample consisted of older adults from the Canadian Community Health Survey 1.2 (n=12,792). Trained lay interviewers assessed psychiatric disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Physical health conditions were based on self-reported diagnoses by health professionals. Multiple logistic regressions examined whether suffering from a physical health condition increased the odds of any assessed anxiety disorder (panic, agoraphobia, social phobia and posttraumatic stress disorder). Multiple linear regressions examined associations between self-rated health and comorbid physical health conditions and anxiety.ResultsAfter adjusting for confounding variables, the presence of chronically painful conditions (i.e., arthritis, back pain and migraine) and of other commonly occurring diseases (i.e., allergies, cataracts and gastrointestinal, lung and heart disease) were positively associated with anxiety. The comorbidity of anxiety with allergies, cataracts, arthritis and lung disease resulted in poorer self-rated physical and/or mental health after adjusting for confounding variables.ConclusionHealth problems in older adults are associated with increased odds of anxiety, and this comorbidity is associated with poorer self-reported health than medical problems or anxiety alone. These findings have important clinical implications for health professionals.     

Association of perceived stigma and mood and anxiety disorders: results from the World Mental Health Surveys

Objective: We assessed the prevalence of perceived stigma among persons with mental disorders and chronic physical conditions in an international study. Method: Perceived stigma (reporting health‐related embarrassment and discrimination) was assessed among adults reporting significant disability. Mental disorders were assessed with Composite International Diagnostic Interview (CIDI) 3.0. Chronic conditions were ascertained by self‐report. Household‐residing adults (80 737) participated in 17 population surveys in 16 countries. Results: Perceived stigma was present in 13.5% (22.1% in developing and 11.7% in developed countries). Suffering from a depressive or an anxiety disorder (vs. no mental disorder) was associated with about a twofold increase in the likelihood of stigma, while comorbid depression and anxiety was even more strongly associated (OR 3.4, 95%CI 2.7–4.2). Chronic physical conditions showed a much lower association. Conclusion: Perceived stigma is frequent and strongly associated with mental disorders worldwide. Efforts to alleviate stigma among individuals with comorbid depression and anxiety are needed.     

Mood and anxiety disorders in patients with chronic low back and neck pain caused by disc herniation

Objective: We investigated the prevalence of mood and anxiety disorders in patients with chronic low back and neck pain caused by disc herniation and the relationships between pain and mood, and anxiety disorders.

Methods: In total, 149 patients with disc herniation and 60 healthy subjects were included. Disc herniation was diagnosed based on a physical examination and magnetic resonance imaging. Mood and anxiety disorders were diagnosed using the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Clinical Version.

Results: The mean age of the study subjects (n?=?209) was 45.96?±?11.45 years. Seventy (46.6%) patients with disc herniation met the criteria for at least one mood or anxiety disorder. The prevalence rates of mood and anxiety disorders were 16.6% and 35.8%, respectively. The most common specific diagnoses were major depression (n?=?25, 16.9%) and generalised anxiety disorder (n?=?19, 12.8%).

Conclusions: Mood and anxiety disorders were more commonly seen in patients with lumbar or cervical disc herniation than in those without herniation. No relationship was detected between pain severity and mood or anxiety disorders. However, mood and anxiety disorders were associated with neurological deficits.     

Psychiatric aspects of pain

PURPOSE OF REVIEW: Pain is a common reason for seeking healthcare. Chronic pain is commonly comorbid with psychiatric disorders. New evidence provides fresh insights into the nature of the link between pain and mental disorders and offers opportunity to refine treatment approaches. RECENT FINDINGS: Even though depression is the most commonly studied comorbid psychiatric disorder, new studies show that other mental disorder, especially anxiety disorders, are also common. Comorbid conditions, including other chronic physical conditions, account for a substantial proportion of the disability associated with chronic pain conditions. The causal link between chronic pain and mental disorders may vary depending on the specific mental disorder, but the link may be mediated by biological, psychological, and social factors. Recent findings also suggest that the evolution of the comorbidity may differ between the sexes. Promising interventions for chronic pain that also target contextual psychosocial problems have been recently described. SUMMARY: The frequent occurrence of mental disorders among patients with pain, especially those whose pain is chronic, has implications for the management of such patients. Current understanding of the complexity of this link not only provides opportunities for designing appropriate interventions but also raises new questions for further research.     

Anxiety and mood disorders in primary care practice

Anxiety and mood disorders are common conditions in primary health care service. Primary care physicians (PCPs) have a privileged role in the early recognition of these conditions. In this study, the prevalence rates of threshold and subthreshold mood and anxiety disorders were surveyed among 1815 primary care attendees in 12 PCPs’ offices in Budapest, using the Diagnostic Interview Schedule (DIS). The 1-year prevalence of DIS/DSM-III-R anxiety and/or mood disorders was 16.8%, and the 1-month prevalence was 12.5%. The occurrence rates of subthreshold anxiety and/or depression were 25.7 and 13.1%, respectively. The impact of threshold anxiety and mood disorders on work performance was considerably higher than the impact of subthreshold symptoms. At the time of the interview, 6.7% of the patients received mood and/or anxiety disorder diagnoses by their PCPs. The measure of agreement between the diagnoses generated by the DIS and the ones given by the PCPs was low. The presence of an acute or chronic physical illness made it more difficult for the PCPs to recognize a psychiatric disorder. Conversely, patients’ psychological complaints significantly improved the recognition of anxiety and/or mood disorders. The use of the Beck Depression Inventory (BDI) brief version would help the patients to reveal their psychological symptoms, and the physicians to recognize an underlying psychiatric disorder.     

Mental-physical comorbidity in Te Rau Hinengaro: the New Zealand Mental Health Survey

OBJECTIVE: To estimate the prevalence of chronic physical conditions, and the risk factors for those conditions, among those with 12 month mental disorder; to estimate the prevalence of 12 month mental disorder among those with chronic physical conditions. METHOD: A nationally representative face-to-face household survey was carried out in October 2003 to December 2004 with 12,992 participants aged 16 years and over, achieving a response rate of 73.3%. Mental disorders were measured with the World Mental Health version of the Composite International Diagnostic Interview (CIDI 3.0). Physical conditions were self-reported. All associations are reported adjusted for age and sex. RESULTS: People with (any) mental disorder, relative to those without mental disorder, had higher prevalences of several chronic physical conditions (chronic pain, cardiovascular disease, high blood pressure and respiratory conditions) and chronic condition risk factors (smoking, overweight/obesity, hazardous alcohol use). Around a quarter of people with chronic physical conditions had a comorbid mental disorder compared with 15% of the population without chronic conditions. Significant relationships occurred between some mental disorders and obesity, cardiovascular disease and diabetes for females, but not for males. CONCLUSIONS: This paper provides evidence of substantial comorbidity between mental disorders and chronic physical conditions in New Zealand. This should be borne in mind by clinicians working in both mental health and medical services.     

Functional disability of mental disorders and comparison with physical disorders: a study among the general population of six European countries

OBJECTIVE: To examine the association of mental and physical disorders with multiple domains of functioning and compare the two. METHOD: Data were derived from the European Study of the Epidemiology of Mental Disorders, a general population study in which adults (n > 21,000) from Belgium, France, Germany, Italy, the Netherlands and Spain were assessed using the Composite International Diagnostic Interview (mental disorders), World Health Organization Disability Assessment Schedule second edition (functional disability) and self-report (physical disorders). Means in different groups were compared using the Mann-Whitney U-test and multiple regression analyses. RESULTS: Mental disorders were related to disability in all domains of functioning: anxiety disorders the most, followed by mood disorders, and finally alcohol disorders. The findings suggest that mental disorders are associated with similar or higher levels of disability in all domains, except getting around, than arthritis and heart disease. CONCLUSION: Mental disorders are associated with a similar or higher negative impact on daily functioning than arthritis and heart disease.     

Clinical differences among patients treated for mental health problems in general medical and specialty mental health settings in the National Comorbidity Survey Replication

OBJECTIVE: General medical (GM) treatments for mental health disorders are less likely than specialty mental health (SMH) treatments to be adequate. We explored whether differences in the clinical characteristics of patients treated in each sector (GM-only or SMH-only) or in both sectors (GM+SMH) may help to explain this finding. METHOD: We analyzed data from the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey of 5692 English-speaking adult household residents that was carried out in 2001-2003. The NCS-R used a fully structured diagnostic interview to assess DSM-IV disorders, including mood, anxiety, impulse control and substance use disorders. We classified disorders in terms of a three-category severity gradient (serious, moderate and mild) based on information about clinically significant distress and role impairment. We collected self-report data on chronic physical conditions, sociodemographics and type of treatment received for emotional and substance use problems in the 12 months before the interview. RESULTS: Patients who received GM+SMH treatment had more severe mental disorders and a higher prevalence of mood and anxiety disorders than patients who received treatment in only one of the two sectors. Patients seen in the GM-only and GM+SMH sectors had more chronic physical conditions than patients seen in the SMH-only sector. CONCLUSION: Patient characteristics may partially explain the lower intensity and adequacy of GM treatment.     

Perceived work stress, imbalance between work and family/personal lives, and mental disorders

BACKGROUND: Occupational mental health research has been focusing on the relationship between work stress and depression. However, the impacts of work stress on anxiety disorders and of imbalance between work and family life on workers' mental health have not been well studied. This analysis investigated the association between levels of perceived work stress and of imbalance between work and family/personal lives and current mood/anxiety disorders. METHOD: This was a cross-sectional study using data from the Canadian Community Health Survey-Mental Health and Well-being (CCHS-1.2) (n=36,984). Mood and anxiety disorders were measured using the World Mental Health-Composite International Diagnostic Interview. RESULTS: The 1-month prevalence of mood and anxiety disorders among those with a work stress score at the 75th percentile value and above was 3.6% and 4.0%. Among those who reported that their work and family/personal lives "never" balanced in the past month, the 1-month prevalence of mood and anxiety disorders was 21.2% and 17.9%. In multivariate analyses, work stress and imbalance between work and family/personal lives were independently associated with mood and anxiety disorders. There was no evidence that perceived work stress interacted with imbalance between work and family/personal lives to increase the likelihood of having mental disorders. Gender was associated with anxiety disorders, but not with major depressive disorder and mood disorders. CONCLUSIONS: Work stress and imbalance between work and family/personal lives may be part of the etiology of mood and anxiety disorders in the working population. Community based longitudinal studies are needed to delineate the causal relationships among work stress, imbalance between work and family/personal lives and mental disorders.     

Mental Health Visits: Examining Socio-demographic and Diagnosis Trends in the Emergency Department by the Pediatric Population

The emergency department (ED) is increasingly being used for mental health visits by children and adolescents. It is estimated that 21–23% of youth have a diagnosable psychiatric or substance use disorder. Using data from the ED of a tertiary medical center, we examined trends in mental health diagnoses over a 5-year period. In school age children the most prevalent diagnoses were anxiety disorders (28.4%); disorders first usually diagnosed in infancy, childhood, or adolescence (26.5%), and mood disorders (18.6%). High school students were more likely to visit the ED for anxiety disorders (30%). Females (34.5%) presented more for anxiety disorders compared to males (22.7%). Mental health visits and diagnoses were higher during school months (September–May) and lower in the summer months (June–August). The diagnosis trends identified in this study have clinical implications that can contribute to evidence-based restructuring of mental health resources and screenings.     

Prevalence of mental disorders among Māori in Te Rau Hinengaro: the New Zealand Mental Health Survey

OBJECTIVE: To describe the prevalence of mental disorders (period prevalence across aggregated disorders, 12 month and lifetime prevalence) among Māori in Te Rau Hinengaro: The New Zealand Mental Health Survey. METHOD: Te Rau Hinengaro: The New Zealand Mental Health Survey, undertaken between 2003 and 2004, was a nationally representative face-to-face household survey of 12,992 New Zealand adults aged 16 years and over, including 2,595 Māori. Ethnicity was measured using the 2001 New Zealand census ethnicity question. A fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (CIDI 3.0), was used to measure disorder. The overall response rate was 73.3%. This paper presents selected findings for the level and pattern of mental disorder prevalence among Māori. RESULTS: Māori lifetime prevalence of any disorder was 50.7%, 12 month prevalence 29.5% and 1 month prevalence 18.3%. The most common 12 month disorders were anxiety (19.4%), mood (11.4%) and substance (8.6%) disorders and the most common lifetime disorders were anxiety (31.3%), substance (26.5%) and mood (24.3%) disorders. Levels of lifetime comorbidity were high with 12 month prevalence showing 16.4% of Māori with one disorder, 7.6% with two disorders and 5.5% with three or more disorders. Twelve-month disorders were more common in Māori females than in males (33.6%vs 24.8%) and in younger age groups: 16-24 years, 33.2%; 25-44 years, 32.9%; 45-64 years, 23.7%; and 65 years and over, 7.9%. Disorder prevalence was greatest among Māori with the lowest equivalized household income and least education. However, differences by urbanicity and region were not significant. Of Māori with any 12 month disorder, 29.6% had serious, 42.6% had moderate and 27.8% had mild disorders. CONCLUSION: Mental disorders overall and specific disorder groups (anxiety, mood and substance) are common among Māori and measures of severity indicate that disorders have considerable health impact. Findings provide a platform for informing public health policy and health sector responses to meeting mental health needs of Māori.     

Overview of key data from the European Study of the Epidemiology of Mental Disorders (ESEMeD)

The European Study of the Epidemiology of Mental Disorders (ESEMeD) is the first large-scale survey to collect data comprehensively on the prevalence, risk factors, disability, and use of health care services associated with mood, anxiety, and alcohol-related disorders throughout Europe. Findings from the ESEMeD study are updated using a modified version of the Composite International Diagnostic Interview 3.0 in order to achieve the maximum diagnostic accuracy. The study is based on a sample of 21,425 noninstitutionalized adults, representative of an overall population of more than 212 million from Belgium, France, Germany, Italy, the Netherlands, and Spain. In total, 25.9% of participants reported a lifetime presence of any mental disorder, and 11.5% had experienced a mental disorder during the past 12 months. Females, younger participants, the unmarried, and the unemployed were more at risk, and comorbidity was prevalent. Associated levels of disability and reductions in quality of life exceeded levels seen in patients with chronic physical conditions. Nevertheless, only 36.8% of participants with a mood disorder and 20.6% with an anxiety disorder sought help from health care services; of these, 20.7% received no treatment. ESEMeD data provide an epidemiologic basis for reform of mental health policy within Europe.     

Use of mental health services in a developing country

BACKGROUND: Evidence from developed industrialized countries suggests poor uptake of mental health services. No data exist in developing resource-constrained countries about met and unmet need for mental health service in the community. METHOD: A four-stage stratified probability sample of households was studied in the Yoruba-speaking part of Nigeria (population, approximately 25 million people or 22% of the Nigerian national population). Face-to-face interviews were conducted with persons 18 years old and above (n=4,984) using the World Mental Health version of the Composite International Diagnostic Interview. We determined the proportions of respondents with 12-month Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety, mood, or substance use disorder who had received any mental health treatment and the correlates of treatment receipt. RESULTS: Only 9.0% of those with any 12-month DSM-IV disorder had received treatment. While 11% of those with a mood disorder had received some treatment, none of those with substance use disorders had used a mental health service. Most treatments were received from general medical settings, with only about 1% of those with DSM-IV disorders receiving specialist mental health service. Surprisingly, complementary or alternative health providers were also consulted by only about 4% of those with mental disorders, although a much higher proportion of 57% of those with no DSM-IV disorders but who nevertheless received mental health treatment did so from such providers. Irrespective of the disorders or the sector where treatment was received, virtually no treatment was adjudged minimally adequate. CONCLUSION: There is a striking level of unmet need for mental health service in the community in this developing country setting. While inadequacy of the formal public health sector may be partly responsible for this observation, there is the likelihood that receipt of treatment for mental health problems may also be hampered by the public's poor knowledge of the nature of the disorders and by stigma.     

Lifetime risk and age-of-onset of mental disorders in the Belgian general population

AIMS: To estimate lifetime risk and age of onset of mental disorders in the adult general population of Belgium. METHOD AND MATERIALS: For the World Mental Health Surveys of the World Health Organization, a representative random sample of non-institutionalized inhabitants from Belgium aged 18 or older (n = 2419) were interviewed between April 2001 and June 2002. The interview took place by means of the Composite International Diagnostic Interview, version 3.0. Lifetime prevalence, projected lifetime risk, and age-of-onset of mental disorders were assessed. RESULTS: Lifetime risk for any mental disorder was 37.1%: 22.8% for mood disorders, 15.7% for anxiety disorders, and 10.8% for alcohol disorders. Median age of onset was 38 years for mood, 14 years for anxiety, and 23 years for alcohol disorders. Prevalence estimates of mood and alcohol disorders were significantly higher in the cohorts between 18 and 34 years. CONCLUSION: This is the first study that assessed projected lifetime risk and age of onset of mental disorders in the Belgian general population. About one-third of the Belgian non-institutionalized adult population will meet the criteria for a DSM-IV mental disorder at some time during their life. Median age of onset varies from disorder to disorder and younger cohorts had higher likelihood for developing mental disorders.     

Perceived need and help-seeking in adults with mood, anxiety, or substance use disorders.

BACKGROUND: A majority of adults with common mental disorders do not seek professional help. To better understand why not, we examined the correlates of various stages of help-seeking, including perceived need for professional help, seeking such help, and from which professionals participants sought help. METHODS: The sample for this study comprised 1792 participants in the National Comorbidity Survey, conducted from 1990-1992, who were diagnosed with a 12-month DSM-III-R mood, anxiety, or substance disorder. In this sample, we assessed correlates of perceived need for professional help, seeking professional help among those with a need, and, among those who did seek professional help, seeking help from mental health professionals. RESULTS: Mood disorders, comorbid mood and anxiety disorders, and mental disorders associated with impairment in role functioning or suicidality were strong predictors of perceived need. Psychopathology was also associated with the decision to seek help from mental health professionals, but not with the decision to seek professional help overall. After controlling for the nature and severity of psychopathology, various sociodemographic and attitudinal factors appeared to be associated with perception of need, help-seeking, and participants' choices of professionals. CONCLUSIONS: Unmet need for mental health care is a serious public health problem. Meeting this need requires expanding our attention beyond psychopathology to various evaluations and decisions that affect help-seeking. Our results suggest the importance of attitude and behavior change strategies in reducing the gap between need and care.