title: Employment status and mental health care use in times of economic contraction: a repeated cross-sectional study in Europe, using a three-level model.
abstract: BACKGROUND
  Framed within the recent economic crisis, in this study we investigate the medical mental health care use of the unemployed compared with that of the employed in Europe, and whether the relationship between employment status and mental health care use varies across macro-economic conditions. We examine whether the macro-economic context and changes therein are related to mental health care use, via their impact on mental health, or more directly, irrespective of mental health.
  
  
  METHODS
  We use data from three waves of the Eurobarometer (2002, 2005/2006, and 2010), which has a repeated cross-sectional and cross-national design. Linear and logistic multilevel regression analyses are performed with mental health, contacting a general practitioner, and contacting a psychiatrist for mental health problems as dependent variables. The multilevel design has three levels (the individual, the period-country, and the country), which allows us to estimate both longitudinal and cross-sectional macro-effects. The macro-economic context and changes therein are assessed using national unemployment rates and growth rates in Gross Domestic Product (GDP).
  
  
  RESULTS
  The mean unemployment rate is negatively related to mental health, although for women, this effect only applies to the employed. Among women, no relationship is found between changes in the macro-economic context and mental health. The unemployment rate, and changes in both the unemployment rate and the real GDP growth rate, are associated with men's care use, regardless of their mental health, whereas this does not hold for women. In countries with an increase in the unemployment rate, both unemployed and employed men tend to medicalize their problems more by contacting a general practitioner, irrespective of their mental health, while the likelihood of contacting a psychiatrist is lower among employed men.
  
  
  CONCLUSIONS
  Our findings stress the importance of taking the macro-economic context and changes therein into account when studying the mental health care use of unemployed people compared with the employed, in particular among men. Moreover, it is important to make the distinction between primary and specialized medical care use, as the impact of macro-economic conditions is dependent on the type of care, which also applies when controlling for mental health.
authors.affiliation: Department of Sociology, Health and Demographic Research group [HeDeRa], Ghent University, Ghent, Belgium. Veerle.Buffel@UGent.be.
authors.forename: Veerle
authors.initials: V
authors.lastname: Buffel
authors.affiliation: Department of Sociology, Health and Demographic Research group [HeDeRa], Ghent University, Ghent, Belgium. Vera.vandeStraat@UGent.be.
authors.forename: Vera
authors.initials: V
authors.lastname: van de Straat
authors.affiliation: Department of Sociology, Health and Demographic Research group [HeDeRa], Ghent University, Ghent, Belgium. Piet.Bracke@UGent.be.
authors.forename: Piet
authors.initials: P
authors.lastname: Bracke
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D057172:Economic Recession; D004651:Employment; D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D008962:Models, Theoretical; D011795:Surveys and Questionnaires; D055815:Young Adult