Social inequality in the utilization of in- and outpatient treatment of non-psychotic/non-organic disorders: a study with health insurance data.
BACKGROUND
This study deals with the utilization of in- and outpatient care due to non-psychotic/non-organic disorders (ICD-9 300-307: neuroses, personality disorders, sexual disturbances, alcohol and substance dependencies, drug abuse and functional disorders). Specifically, it examines whether social gradients to the detriment of individuals from lower social positions appear. This is dealt with both in terms of in- and outpatient treatment. Secondly, it examines whether the likelihood of being treated as an inpatient rather than an outpatient differs between occupational status positions. Finally, the study considers whether the hospital department a given patient is most likely to be assigned to differs between occupational status positions.


METHODS
Analyses were performed with records from a statutory health insurance in West Germany. The database consists of 124,917 men and women between 20 and 60 years of age. We included only subjects with employment periods, as otherwise outpatient treatment could not be assessed completely. The data had been recorded between 1987 and 1996. In total, 9129 persons had one of the above mentioned diagnoses, 6115 of them received outpatient treatment and 3014 were inpatients only.


RESULTS
The relative risk (RR) for outpatient diagnoses was RR=4.41 for the male unskilled/semi-skilled insured in comparison with men in the highest occupational position, the equivalent RR for women was 2.1. The respective results for inpatient treatment were RR=7.3 for men and RR=2.3 for women. In men, the relative risks were considerably reduced after cases with alcohol- and substance-related diagnoses had been excluded. For the assignment to in- and outpatient treatment, no consistent differences between individuals with different occupational positions emerged. Once diagnosed, higher-status individuals had the longest treatment periods as in- and outpatients. Only a small proportion of diagnosed subjects received medical care in psychiatric wards; this held especially for the group with higher occupational positions.


CONCLUSIONS
Social inequalities in the treatment of psychogenic disorders emerged for outpatients as well as for inpatients. Inpatients tended to avoid treatment in psychiatric departments, and it can be concluded that individuals holding higher positions may be more successful in their attempts to avoid stigmatization.
Geyer
S
S
Medical Sociology, Medical University of Hannover, Germany. geyer.siegfried@mh-hannover.de
Haltenhof
H
H
Peter
R
R
D000328:Adult; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D015986:Confounding Factors, Epidemiologic; D005260:Female; D005858:Germany; D006801:Humans; D007358:Insurance, Psychiatric / Q000706:statistics & numerical data*; D008297:Male; D008499:Medical Records; D001523:Mental Disorders / Q000175:diagnosis / Q000628:therapy; D008605:Mental Health Services / Q000458:organization & administration / Q000706:statistics & numerical data*; D008875:Middle Aged; D009790:Occupations / Q000145:classification; D011287:Prejudice; D011567:Psychiatric Department, Hospital / Q000706:statistics & numerical data*; D012017:Referral and Consultation; D012189:Retrospective Studies; D017678:Sex Distribution; D012923:Social Class; D013240:Stereotyping