Elimination of copayments doubles visits to the psychologist and decreases suicide among young adults

In a new study, Danish researchers have found that abolishing co-payments doubles the number of 18- to 21-year-olds receiving psychotherapy. This was associated with a 25% reduction in suicide attempts. The likelihood of receiving outpatient psychiatric care and antidepressants also increased.

These effects were more pronounced among low-income adolescents, meaning that the absence of co-payments likely increases equality of access to mental health care.

The researchers write: ‘We show that after removing the co-payment, the use of psychological treatment almost doubles. We find that this increase involves moderately positive spillover effects on outpatient psychiatric care and antidepressant prescriptions. In the heterogeneity analysis, we find evidence of larger effects on adolescents from low-income families, indicating that reducing user fees can increase equity of access.

The study was published in health economics and led by Marie Kruse at the Danish Center for Health Economics (DaCHE) at the University of Southern Denmark.

Psychological disciplines have struggled to predict and prevent suicide attempts. Screening designed to detect suicidal ideation early does not prevent hospitalization or suicide attempts and may expose adolescents to unnecessary treatment. Research has shown that antidepressants increase suicidal tendencies and violence among users. Lithium also fails to prevent suicide attempts at a higher rate than placebos.

A study has found that the social dynamics of school greatly influence adolescent suicide, with researchers pointing out that adolescents’ relationships with adults, popularity, close friendships and ties to school all play key roles. Similarly, other research has found that deteriorating relationships with teachers and bullying at school increase suicidality in adolescents who have previously been hospitalized.

Adolescent sexual minorities are at significantly increased risk of suicide compared to their heterosexual counterparts. Researchers have also found that childhood adversity increases the risk of suicide in adolescents. The use of antidepressants also increases the risk of suicide in children without evidence of benefit. One study found that using antidepressants increased the risk of suicide by 2.5 times compared to non-users.

A growing number of researchers and practitioners are calling for a change in the way psychic disciplines attempt to prevent suicide. A United Nations expert has called for a shift from medical solutions to suicide to a rights-based approach designed to make life more livable. Similarly, other researchers have called for a social justice approach to suicide prevention.

Current work begins by explaining that user fees for mental health care are generally higher than for physical health care. According to the authors, this results in an under-treatment of mental health problems. A 2006 study in Denmark found that the most common reason for hospitalization and one of the most common causes of death among 15 to 34 year olds was attempted suicide. With 10% to 20% of teens suffering from a mental health problem, many are likely going untreated. The authors suggest that high out-of-pocket payments lead to underutilization of mental health care, which in turn leads to increased suicidality.

To test this hypothesis, the authors looked at data from 1.2 million people in Denmark regarding user fees, use of mental health services and suicidal tendencies. They assessed how the elimination of copayments affects the use of psychologists and studied “ripple effects” on other outpatient mental health services, antidepressant prescriptions and suicide attempts.

In 2018, the Danish government launched a pilot program that eliminated user fees for people aged 18 to 21 who were referred to a psychologist for anxiety or depression. The authors compared the data associated with this group without co-payment to populations of the same age (16-17 years and 22-23 years) who still had to fulfill co-payments for visits to the psychologist.

During the study, the non-copayment group saw a psychologist for anxiety or depression at twice the rate of the control groups. The non-copay group also had fewer referrals to trauma psychologists (one referral that did not require a co-pay even before the 2018 pilot study). According to the authors, this indicates both that mental health care is probably underutilized in populations with co-payments, and that general practitioners were probably making more referrals for trauma, rather than for anxiety or depression, prior to the program, due to his full coverage status. without copayment.

The authors report that outpatient psychiatric care for the non-copay population increased by 7.5% during their study. Antidepressant prescriptions also increased by 11% for the non-copayment group. Over the period of this study, suicide attempts for the non-copayment population were reduced by 25% compared to their counterparts who still had to pay to see a psychologist for anxiety or depression (9.9 attempts per 100,000 people -months versus 7.5 attempts for 100 months). .00 person-months).

The decrease in suicide attempts was most pronounced among low-income young men and high-income young women, with low-income men seeing a 69% reduction in suicide attempts and high-income women seeing a reduction in suicide attempts. 130% compared to their counterparts who still had to make co-payments.

The researchers conclude: “Removing user fees from frontline mental health care can have a positive impact on mental health and well-being, as measured by reduced suicide attempts, in a low-income country. high with high levels of universal coverage. . We further conclude that lower co-payments may increase equity of access to care, as lower-income adolescents tend to experience the highest increases in utilization.

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Kruse, M., Olsen, KR and Skovsgaard, CV (2022). Co‐payment and adolescent use of psychological treatment: spillover effects on mental health care and suicide attempts. Health economics. https://doi.org/10.1002/hec.4582(Summary)

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