A PROFILE OF CANADIAN CONSUMERS OF PSYCHOLOGICAL SERVICES
John Hunsley Ph.D., Tim Aubry Ph.D., & Catherine Lee, Ph.D.
School of Psychology, University of Ottawa
Funded by the Canadian Psychological Association and
the Canadian Register of Health Service Providers in Psychology
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Final Report, August 1997
TABLE OF CONTENTS
Executive Summary | Introduction | Sociodemographic Characteristics | Health Status | Health Care Utilization | Psychosocial Characteristics | Concluding Comments | References | Appendix
In June 1994, Statistics Canada began collecting the first wave of data in their National Population Health Survey (NPHS). The survey was designed to assess the health status of Canadians based on data collected from a representative sample of Canadian households. Subsequent cycles of data collection will occur every 2 years, and will include both cross-sectional information and data from a subset of individuals interviewed in the previous waves of data collection. Information on the development and conduct of the NPHS can be found in Catlin and Will (1992), Stephens (1991), and the National Population Health Survey Overview (1995).
Analysis of the data from the first wave of the NPHS provides an important opportunity to develop a nationally representative profile of the consumers of psychological services in Canada. Knowing who these consumers are and knowing how they compare to the general Canadian population should provide information that is critical in educating healthcare stakeholders such as policymakers, healthcare providers, and the Canadian public about the use of psychological services. Data-based information on the characteristics of users of psychological services should be an integral component of any such educational efforts.
NPHS SURVEY OVERVIEW
At completion in June 1995, data were obtained from 26,430 Canadian households (an 89% response rate). The target population for the survey included Canadian households in all provinces, with the exclusion of populations in the Yukon and Northwest Territories and some remote areas of Ontario and Quebec. Additionally, samples were not drawn from populations living on Indian Reserves, Canadian Forces Bases, and those living in institutions (e.g., long term residents of hospitals or residential care facilities).
The basic survey design was a multi-stage stratified sample of households selected within geographic and/or socioeconomic clusters. In each household, some information was collected about all household members. In-depth interviews were held with one randomly selected household member, aged 12 years or over. Accordingly, the panel of respondents to the survey under-represents people living in large households, as they had a lower chance of being selected for the in-depth interviews. The selected person response rate was 96% for the NPHS, yielding information from over 17,600 individuals.
Data were collected by computer-assisted interviewing. In most cases, respondents were first contacted in person, with subsequent interviews usually conducted on the telephone. The average time for completion of an interview was one hour.
THE CONSUMER PROFILE
The data used to generate the profile of consumers of psychological services came from the interviews with selected household members (i.e., the sample of approximately 17,600 people). As part of the interview, all respondents were asked the following question: How many times have you consulted with a psychologist in the past 12 months? In the overall context of the survey, respondents were directed to provide information about their physical/emotional/mental health. Therefore it can be assumed that these contacts with psychologists would have been in the realm of health service provision. Based on the survey data, approximately 2.15% of respondents indicated that they had consulted a psychologist at least once during the past 12 months. In terms of population estimates, this is equivalent to almost 515,000 Canadians aged 12 years and older who consulted a psychologist. (The data from the entire household yields a similar estimate, with 2.02% of the population having at least one consultation with a psychologist).
The following tables present a breakdown of the survey data in terms of a number of sociodemographic, health status, healthcare utilization, and psychosocial characteristics. There are two basic formats for the tables, with separate estimates for those who did and did not consult a psychologist in the past year. When the values presented in the tables are summed by column they address the question "what percentage of those who consulted a psychologist have the characteristic in question?". When the values presented in the tables are summed by rows they address the question "of those with the characteristic in question, what percentage consulted a psychologist?". In row-summed tables, a general interpretive guideline is that any value in the column for those who consulted a psychologist that is substantially different from 2% of the population (i.e., 2% is the overall percentage of the population that consulted a psychologist) represents an over- or under-representation among the clients of psychologists. For example, in Table 23, 10% of individuals who described themselves as "so unhappy that life was not worthwhile" had consulted with a psychologist. This represents a five-fold greater rate of psychological consultation among these individuals compared to the general population. As the values represented in all tables are population estimates, it is not necessary to conduct statistical analyses to determine whether differences are significant.
In many cases, the sociodemographic, health status, healthcare utilization, and psychosocial characteristics provided in the tables are drawn directly from single questions. The NPHS database does contain, however, a number of derived variables—that is, composites of two or more survey items. To assist the reader in understanding the exact manner in which these variables were assessed, complete listings for the items used for these variables are presented in the appendix.
Although these findings provide an informative overview of the use of psychological services in Canada, there are several limitations to the data. First, the exclusion from the sample of those living in institutions and reserves, and those who are homeless, is likely to result in data that are not generalizable to these populations. Second, the survey method requires retrospective recall from respondents. There is extensive psychological research that indicates that caution should be used in interpreting such data as uniformly accurate (e.g., Ptacek, Smith, Espe, & Raffety, 1994; Shiffman et al., 1997). Third, respondents did not provide information on the nature of services received from psychologists. It is possible, therefore, that "consultation" with a psychologist may encompass diverse services including assessment, intervention, or treatment. Fourth, the survey did not define the setting in which psychological services were delivered, so it is not possible to distinguish between privately and publicly funded psychological services. A final caution relates to the use of the term "psychologist" which may be used with varying degrees of precision depending on the respondents' familiarity with the roles of various mental health professionals.
SOCIODEMOGRAPHIC CHARACTERISTICS
Men and women each comprised 50% of the survey sample. However, of those who consulted a psychologist in the past 12 months, 66% were women and 34% were men. This is consistent with the general findings of the NPHS that women were more likely to men to consult health service providers (National Population Health Survey Overview, 1995). It is also consistent with research indicating women are more likely than men to use mental health services (Lin, Goering, Offord, Campbell, & Boyle, 1996; Vessey & Howard, 1993). Table 1 presents information on the age of those who consulted a psychologist. Consistent with American estimates for the use of mental health services (Vessey & Howard, 1993), the percentage of those who consulted a psychologist bulged in late adolescence, peaked in mid-life and then tailed-off among the elderly. Tables 2 and 3 present the age breakdown by gender. Table 4 presents information on marital status.
Table 1 | Table 2 | Table 3 | Table 4
Tables 5 and 6 present information on the educational level and work status of respondents. Although the distributions are generally comparable for those who did and did not consult a psychologist, it appears that those with the highest level of education were somewhat over-represented among those who consulted a psychologist.
Table 7 provides information on the household income of respondents. Overall, the distribution of those who did and did not consult a psychologist appears comparable, although there appears to be a slight over-representation of those in the highest income brackets among psychologists’ clients. This may be a result of psychological services being provided both in publicly funded health care institutions and in the private health care sector.
Tables 8 and 9 provide information on the living arrangements of respondents. The distributions of those who did and did not consult a psychologist are comparable. One exception to this appears to be the over-representation of adults and children living in single-parent families. This is consistent with the results of the recent National Longitudinal Survey of Children and Youth that found these children are likely to experience higher rates of emotional and behavioural difficulties than are children from two-parent families (Lipman, Offord, & Dooley, 1996).
Tables 10 and 11 present information on respondents’ province of residence. Additional analyses revealed that overall, 1% of those living in rural settings consulted a psychologist, whereas the figure was 3% for those living in urban areas. This difference is probably due, at least in part, to the greater availability of psychological services in urban areas compared to rural areas.
A number of questions in the NPHS dealt with the health status of respondents. Table 12 presents respondents' subjective ratings of their overall health. Table 13 provides a generic health status index, based on information provided by respondents regarding their vision, speech, hearing, mobility, dexterity, cognition, emotion, and pain/discomfort. In both tables it is evident that, compared to the general population, those who consulted with a psychologist were less likely to report the highest health status levels.
Tables 14 and 15 present data that show, in general terms, the physical activity level of those who consulted a psychologist is similar to those who did not. However, these global representations mask some important differences between those who did and did not consult a psychologist. As indicated in Tables 16 and 17, individuals with pain and with substantial mobility problems are over-represented among the clients of psychologists. Furthermore, 25% of those who consulted a psychologist (compared to 17% of those who did not) indicated that they had received an injury in the past year in the past year that was serious enough to limit normal activities.
Table 14 | Table 15 | Table 16 | Table 17
Table 18 indicates that the level of alcohol consumption was comparable among those who did and did not consult a psychologist.
A number of questions regarding the use of health services were asked of the NPHS respondents. Of those who consulted a psychologist, 17% (compared to 9% of those who did not consult a psychologist) had been a patient over-night in a hospital, nursing home, or convalescent home in the past year. As indicated in Table 19, individuals who had frequent contact with their family physician were also more likely to consult a psychologist than were those who contacted their family physician infrequently. Moreover, individuals who consulted a psychologist were also more likely to have consulted an alternative health care provider in the past year. Fifteen percent of psychologists’ clients (compared to 5% of those who did not consult a psychologist) had consulted professionals such as acupuncturists, naturopaths, massage therapists, and herbalists.
Exact information the nature of the consultation with these health service providers is not available in the NPHS. It is, however, important to note that prior research has demonstrated that psychosocial problems are causally linked to many of the concerns for which people consult primary care physicians (e.g., Diekstra & Jensen, 1988; VandenBos & DeLeon, 1988). As such, it is likely that psychologists may be able to provide important services to individuals who frequently consult physicians. Moreover, available evidence strongly suggests that the use of such psychological services is cost-effective for the health care system (Groth-Marnat & Edkins, 1996).
Information was also obtained in the NPHS on medication use among Canadians. Of those who did not consult a psychologist, 2% had used antidepressants, 2% had used tranquillizers, and 3% had used sleeping pills. In contrast, the rates of use among psychologists’ clients were 20%, 11%, and 8%, respectively. Tables 20 to 22 present further information on the use of antidepressants, tranquillizers, and sleeping pills. As is commonly found, the rate of use of these medications was higher among women than among men.
Table 20 | Table 21 | Table 22
It is clear that, compared to the general population, those who consulted a psychologist were more likely to have taken these three types of medications in the past year. On the other hand, the vast majority of individuals taking these medications had not consulted a psychologist. Given (a) that there are effective psychological interventions for the problems for which these medications are routinely prescribed (Chambless et al., 1996) and (b) the often expressed concerns about side-effects and compliance problems with psychoactive medication, psychologists are likely to have much to offer these individuals (cf. Barlow, 1994). In sum, these findings suggest that there are many Canadians who could benefit from psychological services.
A sizeable portion of the NPHS was devoted to mental health and psychosocial functioning. The following tables present information on a range of these characteristics, such as emotional well-being, current stressors, and job satisfaction. As indicated in Table 23, half of those who consulted a psychologist described themselves as being generally happy. Although individuals who describe themselves as unhappy comprise about 12% of those who consult psychologists, it is clear from Table 24 that the vast majority of those who are unhappy did not consult a psychologist. It is particularly noteworthy that only 10% of those who felt that life was not worthwhile consulted with a psychologist.
Tables 25 to 27 provide information on stressors experienced by Canadians. In Table 25, information is provided on the number of major stressors experienced during the childhood and adolescence of individuals (including such events as parental divorce, long hospitalization, prolonged parental unemployment, and parental alcohol or drug abuse). In Table 26, information is provided on the number of ongoing, chronic stressors (including such stressors as activity overload, financial difficulties, and relationship problems). In order to take into account that some possible stressors may not be relevant for each respondent (e.g., because of age considerations), an adjusted index is used (see appendix for details). In Table 27, information is provided on the number of recent negative life events (i.e., in the past 12 months) experienced directly or indirectly (i.e., by a close friend or family member). Included in these negative events are such events as physical abuse, miscarriage, and serious work or school problems. An adjusted index is again used (see appendix) to take into account that some possible events may not be relevant for each respondent (e.g., because of age considerations). In all three tables it is evident that, compared to those who did not consult a psychologist, the distribution of those who consulted psychologist is shifted toward the higher numbers of stressors, both past and current. Further analysis indicates that high levels of current stress are associated with greater frequency of consultations with physicians. This is consistent with a large literature on the association between stress, distress, and health service utilization (Gortmaker, Eckenrode, & Gore, 1982).
Table 25 | Table 26 | Table 27
From the data presented in Table 28, it appears that the levels of job satisfaction are comparable for those who did and did not consult a psychologist in the past year.
The following tables are based on a series of questions from the Composite International Diagnostic Interview (CIDI) that were included in the NPHS. Table 29 presents information on the level of emotional distress experienced in the past month. Based on responses to a series of items designed to tap depressive symptomatology and the duration of symptoms, Tables 30 and 31 provide information on the probability of people meeting diagnostic criteria for depression as outlined in DSM-III-R (Major Depressive Episode). From the data in these tables, it is clear that a substantial number of individuals who consulted a psychologist were experiencing very elevated levels of distress. However, it is also evident that only a minority of those who were likely to meet diagnostic criteria consulted a psychologist. Given that there are a number of effective psychological interventions for depression (Chambless et al., 1996), it is clear that psychological services are under-utilized by depressed individuals.
Table 29 | Table 30 | Table 31
Individuals experiencing depression have been shown to be more frequent users of all types of inpatient and outpatient health care services (Simon et al., 1995). It is therefore, very important to understand the services that these individuals receive. In the NPHS, respondents were also asked if they had consulted with a social worker or counsellor in the past year. Among the clients of social workers or counsellors, 21% were likely to criteria for a diagnosis of depression (i.e., 90% probability of depression caseness). Additional analyses revealed little overlap between the depressed clients of psychologists and those of social workers or counsellors, suggesting that depressed clients are unlikely to be seen by both a psychologist and a social worker or counsellor.
As indicated previously, the data indicate that 2% of Canadians had taken antidepressant medication in the past year. However it appears that approximately 5% of Canadians would be likely to meet criteria for a diagnosis of depression. Although the tolerance limits of the NPHS database do not allow for an exact estimate, the data indicate that only a minority of the individuals who were taking antidepressant medication were those most likely to receive a diagnosis of depression. Further analysis of the NPHS data reveal that 12% of those who consulted a psychologist were likely to be depressed and to have taken antidepressants.
Taken together, these data suggest that the majority of depressed individuals are not receiving either antidepressant medication or psychosocial interventions from a psychologist, social worker, or counsellor. There is a pressing need for such individuals to receive effective treatment for their depression, given the deleterious effects of depression on affected individuals and their families (Lee & Gotlib, 1994).
The foregoing pages provide extensive information on the characteristics of those who consult psychologists in Canada. Two themes consistently emerge from these data. The first is that there appear to be two distinct groups of individuals who consult psychologists. As indicated in many of the tables on health status and psychosocial characteristics, the majority of those who consult psychologists are relatively healthy. There are, however, significant numbers of people consulting psychologists who have extensive physical and/or psychological difficulties. It is critical, therefore, that any overall presentation of the nature of psychological services in Canada recognize (a) the range of clients seen by psychologists and (b) the range of services provided by psychologists (Hunsley & Lefebvre, 1990).
A second theme emerging from these data is what can only be described as under-utilization of psychological services. As indicated in the tables that presented data on overall health, stress, distress and depression, there are many Canadians in need of services to improve their physical and mental health. Substantial evidence exists that psychological interventions are both clinically effective for a wide range of mental and physical disorders (Barlow, 1994; Chambless et al., 1996; Roth & Fonagy, 1996; Wilson & Lipsey, 1993) and cost-effective for the health care system (Groth-Marnat & Edkins, 1996). Unfortunately, the public appears to be ill-informed about the nature of psychological services and routes to access these services (Farberman, 1997). As well, the lack of insurance coverage for psychological services for a significant segment of the Canadian population likely contributes to this gap between population needs and service utilization (Rochefort, 1992). It is clear that greater efforts on the part of both individual psychologists and psychological associations is necessary to (i) inform Canadians and Canadian policy makers about the health benefits that can result from high quality psychological services and (ii) reduce the barriers faced by certain segments of the Canadian population to access to these services.
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