Social inequalities in the utilization of outpatient psychotherapy: analyses of registry data from German statutory health insurance

Jelena Epping, Denise Muschik, Siegfried Geyer

Most studies on health disparities deal with the occurrence of disease, but little is known about inequalities in the utilization of mental health services. This paper examines social inequalities in the utilization of outpatient psychotherapy within a health care system where there are low financial barriers to health care and a lack of specific health policies to address access to psychotherapeutic services. Registry data of German statutory health insurance for the year 2013 were used (total population: N = 746,963; 10,711 women and men with psychotherapy). Logistic regression analyses were performed to estimate the effects of three socio-economic (SES) indicators on the utilization of psychotherapy. Utilization of psychotherapy by SES status did not correspond to the social structure of the insured population. Social disparities that disadvantaged less privileged women and men were found; this applied to education, income and occupational position. The most pronounced differences were found for education. In contrast, effects of income were rather small. These findings must be interpreted against the backdrop of the absence of financial barriers to outpatient psychotherapy in Germany. A marked degree of psychotherapy under-utilization was found for lower SES groups. Psychotherapists should pay increased attention to clients with lower socio-economic position. Enhancing mental health literacy, as well as reducing the stigma of mental illness, is crucial for increasing the usage of psychotherapeutic services of those who need it most. Relevant health policy is needed to reduce the barriers to, and consequently increase psychotherapy utilization.