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治疗。除了结构性因素外，这种待遇差距的原因还在于受影响的人的知识水平和态度。在社会学和医学的交叉点，价值取向和生活方式之间与精神卫生保健提供的相互依赖关系是这种治疗差距的一个未充分研究的决定因素。在考虑价值观和个人主导的生活方式的同时，有可能理解寻求精神科治疗的社会过程，这使得像“社会环境”这样的概念成为卫生服务研究的一个有前途的工具，迄今为止很少被利用。对相关价值观、原则和生活方式的首次解释应该有助于制定新的和迫切需要的替代假设来解释治疗差距，并开发有效的工具来方便地测量与精神病学供应不足相关的环境因素，以扩大现有的理论。目的是在一项分三个阶段的初步研究中确定具有特别高的治疗差距风险的社会环境。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，区分西波美拉尼亚农村和结构薄弱示范区精神病供应不足的社会人口决定因素。第2阶段设想对2 × 20名有抑郁症状的受试者（未寻求帮助的风险组N = 20；寻求帮助的对照组N = 20）进行随访，特别关注寻求帮助的背景。指导访谈（“扎根理论”）将用于衡量与专业心理健康支持有关的相关内隐和外显价值观和生活方式，以提高对这一高危人群的了解。在第三阶段，将把第一阶段和第二阶段的成果综合为有很高治疗差距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后，将开发一种复杂的干预措施，以减少受影响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，提高我们对社会环境影响的理解至关重要，因为已经处于不利地位的社会环境可能面临进一步被排除在供应之外的风险。面向病人的精神卫生保健作为开放社会的一个组成部分，应该对来自所有社会背景的人具有足够的吸引力和尽可能容易获得。

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.