A matter of contextcultural and institutional influences on healthcare seeking for mental distress in lithuania and spain

Resumen

Two arguments can be identified in the study of help seeking for mental distress. On the one hand, it is frequently stressed that treatment gap and delay for depression or anxiety disorders remain considerable. The undertreatment of such common mental disorders is associated with substantial health, economic, and social costs. On the other hand, there are those who defend that said unmet needs for mental healthcare are overestimated. They highlight the process of increasing medicalisation of non-disordered mental distress and suggest a range of threats and losses that this may bring about for societies. In this thesis by publication, therefore, I aim to better understand such processes by examining how cultural and institutional contexts impact healthcare seeking for mental distress in Lithuania and Spain, that is, in two settings that appear to diverge with regard to the extent of under- or overtreatment. The thesis consists of six stand-alone articles. Building upon Pierre Bourdieu’s sociology, the first publication is primarily a theoretical contribution to the debates. The remaining five articles, nevertheless, present empirical findings. They draw on 44 in-depth interviews with healthcare providers and users of services with self-reported diagnosis of depression or anxiety disorders, which I conducted in Lithuania and Spain. Through these contributions, I explore how the process of help seeking for mental distress is shaped by health system design and functioning, as well as by the cultural context in which individuals live and acquire their dispositions to think and act. The articles are guided by the works of Pierre Bourdieu and Norbert Elias, as well as by the literature concerning medicalisation, stigma of mental illness, or gender and health. I demonstrate that accessibility of care does not necessarily result in its appropriateness or acceptability. While mental healthcare is perceived to be relatively accessible in the two countries, this appears to mask ideologically-laden gaps or disparities of power within the treatment system. The logic of the mental healthcare field, in turn, may lead to undertreatment of disordered mental distress and/or overtreatment of emotions that are intense but contextually appropriate and proportionate. I argue that whether one or both of such processes become salient is also shaped by cultural context or shared propensities to think about mental health and disorders in determinate ways. In Spain, undertreatment of severe mental illness appears to co-exist with medicalisation of non-disordered distress. Yet, the latter does not seem to be notably present in Lithuania, where the critical issue is the immensity of individuals’ unwillingness to seek healthcare. It is concluded that the interplay between the institutional and the cultural influences the logic of practice and the direction of the medicalisation process. I close the thesis with the discussion of its scholarly contribution, limitations, policy implications, and possible directions for future research. The thesis contributes to sociological accounts addressing mental health, medicalisation, health policies, stigmatisation, and power relations. It also adds to the sociological theory by demonstrating how the theoretical perspectives of Pierre Bourdieu and Norbert Elias can be integrated in order to analyse different aspects of the same process, and in turn, to achieve a better understanding of help-seeking behaviour and healthcare utilisation trends. Keywords: Medical sociology, medicalisation, mental health and illness, mental distress, healthcare systems, culture, help seeking.