While some may choose on their own to seek help for untreated mental illnesses, others can be substantially influenced by others or coerced into care by court order. Understanding variations through which people enter mental health care-by choice or coercion-according to Sirry Alang, an assistant professor of sociology and anthropology at Lehigh University, will enable health care providers to remove barriers to mental health care and ensure that people who need treatment receive it in a timely fashion.

A new study, led by Alang, finds that people who independently seek mental health care are more likely to rate their treatment as effective, compared to people ordered into care.

"Pathways to Mental Health Services and Perceptions about the Effectiveness of Treatment" used data from the 2010-2014 National Survey on Drug Use and Health (NSDUH) to investigate how a person enters mental health care-via individual choice or coercion-and whether or not that path is associated with how one perceives the care.

Coercion into mental health care occurs when individuals are required to get care outside of their own agency. Two types of coercion may occur: informal coercion or formal coercion.

Patients who are pressured by family members (informal coercion) or legally coerced into care by the issuance of court orders for commitment (formal coercion) are both entering mental health care outside of their own volition and according to this study, published online recently in Society and Mental Health (SMH), this affects whether or not the patient believes that the treatment was effective.

Alang notes that how someone enters mental health care is not a random process, nor is it primarily driven by clinical status. She says, "social characteristics associated with social status shape whether one chooses to receive care, was pressured by others, or was ordered into care."

"A piece of this research finds that Blacks are 86% more likely to be ordered into mental health care than Whites," she says. In addition, the findings showed that Blacks had 21% lower odds of rating treatment as effective-aiding in the study's finding that those who entered mental health care independently were more likely than those who had been coerced into care to believe the care was effective. "This matters because people who subjectively believe that treatment is effective experience quicker recovery from mental illness," she notes.

Results suggest three important points:

demographic and socioeconomic characteristics shape how one enters mental health care and the perceptions of the effectiveness of treatment;

the pathway to mental health care is associated with perceptions about the effectiveness of treatment;

the severity of a mental illness affects the strength of the relationship between the pathway to care and the perceived effectiveness of treatment.

Demographic, socioeconomic influence perceptions and effectiveness of mental health care

Alang writes, "our finding that Whites, persons with a college degree, and persons who were employed were less likely to enter into care as a result of an order suggests that pathways into care might reflect positions within the social hierarchy."

Patients ordered into mental health care are more likely to be African American and Latino compared to persons who entered care independently and those who reported being ordered into care also face greater socioeconomic disadvantages including lower educational attainment and high unemployment rates than persons who entered into care independently.

African Americans surveyed for this research were less likely to rate their care as effective than married and college educated respondents. In addition, patients who perceived treatment or counselling as effective were also more likely to rate their overall health as good, and were less likely to have a substance use problem or severe mental illness in the past year.

Alang and her colleagues also find that persons who independently sought mental health care were more likely to rate treatment as effective compared to persons ordered into care.

Pathway to mental health care and perceptions about the effectiveness of treatment

Positive outcomes are more likely to occur when individuals get into care on their own or through encouragement from peers rather than being ordered into care.

People who sought mental health care because of the influence of someone else or those were ordered into care were less likely to rate their treatment as helpful. In addition, those who rated their overall health as good, very good or excellent were more likely to think that treatment was effective compared to those who rated their health as fair or poor

Alang and her colleagues found two demographic factors - race and age - to be associated with perceived effectiveness of treatment. Compared to whites, African Americans had 21% lower odds of rating treatment as effective and older age was associated with greater odds of perceived effectiveness of treatment.

Severity of mental illness affects relationship between pathway to care, perceived effectiveness

Among people with severe mental illnesses, the probability of rating treatment as effective is lowest among those who were ordered into care, she explains.

"Our study shows that severe mental illness was associated with a 29% increase in the probability of being ordered into care compared to seeking care independently."

According to the results of the study, for those whose mental illness was severe, the odds of rating treatment as effective was highest if they were asked by others to seek care and lowest if they sought care because they were ordered to.

In contrast, the results show that for those whose mental health problems were not severe, the predicted probability of perceived treatment effectiveness was highest if they independently sought care.

In the absence of a severe mental illness, Alang says the predicted probability of rating treatment as effective is 9% higher if entry to care was independent rather than if individuals were ordered to seek care.

Removing barriers in the mental health care system

Alang explains that while effectiveness, like receipt of treatment, may be influenced by social characteristics, there has been little research about whether these perceptions are also shaped by whether one enters treatment due to their own agency or are encouraged by others or are forced into care.

Alang and her co-author suggest implementing programs that promote self-entry into care as empowering is important. "This is particularly relevant for Blacks, Latinos, young persons between 18 and 34, and persons without a high school education who are disproportionately coerced into care," they write.

She further explains that understanding how people come to seek care will enable health care providers to remove barriers to care and to ensure that people who need treatment receive it in a timely fashion.

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