The treatment gap in mental health care in a rural German region: from a concept of social milieu to a group-specific intervention. An interdisciplinary model study using epidemiological data

在德国，超过一半的精神疾病患者从未接受过专业的精神支持。除了结构性因素外，造成这种待遇差距的原因还在于受影响人员的知识水平和态度。在社会学和医学的交叉点上，价值取向和生活方式之间的相互依存关系是这种治疗差距的一个研究不足的决定因素。在考虑到价值观和个人主导的生活方式的同时，理解寻求精神治疗的社会过程的可能性，使得像社会环境这样的概念成为卫生服务研究的一个有希望的工具，到目前为止，这种工具还很少被利用。首次阐明相关的价值观、原则和生活方式应有助于形成新的和迫切需要的替代假说来解释治疗差距，并开发有效的工具，方便地衡量与精神疾病供应不足相关的环境因素，以期扩大有关这一问题的现有理论。目的是在分三个阶段的初步研究中确定具有特别高风险的治疗差距的社会环境。第一阶段致力于根据正在进行的流行病学调查的现有数据，在农村和结构薄弱的模范地区西波美拉尼亚区分精神病供应不足的社会人口学决定因素。第二阶段设想2×20名有抑郁症状的受试者(未寻求帮助的风险组N=20人；寻求帮助的对照组N=20人)接受跟进，特别侧重于寻求帮助的背景。指导访谈(“扎根理论”)将被用来衡量与专业精神健康支持相关的隐性和显性价值观和生活方式，以增进对这一高危人群的了解。在阶段3中，阶段1和阶段2的结果将被综合为具有治疗差距高风险的农村人口的社会环境概念。在对正在进行的调查中的结构相关性进行基于项目的评估之后，将制定复杂的干预措施以缩小受影响的风险人群之间的治疗差距。鉴于社会不平等和公众两极分化，加强我们对社会环境的影响的了解至关重要，因为已经处于不利地位的社会环境有可能进一步被排除在提供服务之外。作为开放社会的一项内容，以病人为中心的精神卫生保健服务对所有社会背景的人都应具有足够的吸引力，并尽可能容易获得。

More than half of all people with mental illness in Germany have never availed themselves of professional psychiatric support. Besides structural factors, the causes for this treatment gap can be found in the level of knowledge and in the attitudes of the persons affected. The interdependencies between value orientations and lifestyles in relation to psychiatric health care provision at the intersection of sociology and medicine are an under-researched determinant of this treatment gap.The possibility to understand the social process of seeking psychiatric care while taking values and individually dominating lifestyles into consideration makes constructs like ‘the social milieu’ a promising instrument for health services research that has to date only rarely been drawn on. The first-time explication of relevant values, principles and lifestyles should help with the formulation of new and direly needed alternative hypotheses for explaining the treatment gap, and to develop valid instruments that facilely measure milieu factors relevant for psychiatric undersupply, with a view to expanding existing theories on the matter.The aim is to identify social milieus that bear a particularly high risk of a treatment gap in a three-staged preliminary study. Stage 1 is devoted to distinguishing the sociodemographic determinants of psychiatric undersupply in the rural and structurally weak model region Western Pomerania on the basis of present data from an ongoing epidemiological survey. Stage 2 envisages that 2 x 20 subjects with depressive symptoms (risk group that has not sought help N = 20; control group that has sought help N = 20) undergo follow-up with a special focus on the help-seeking context. A guided interview (“Grounded Theory”) will be used to measure relevant implicit and explicit values and lifestyles in relation to professional mental health support in order to improve understanding of this high-risk population. In stage 3 the outcomes of stages 1 and 2 will be synthesized to social milieu concepts for a rural population with a high risk of a treatment gap.After an item-based evaluation of the construct relevance in ongoing surveys, a complex intervention to reduce the treatment gap among the affected risk-population will be developed. In light of social inequality and public polarization, improving our understanding of the impact of social milieus is of pivotal importance, as social milieus that are already disadvantaged could be at risk of being excluded from provision even further. Patient-oriented psychiatric health care provision as an element of an open society should be sufficiently attractive and as easily accessible as possible for persons from all social backgrounds.