The main finding of the current study is that 17.8 % of people with anxiety/depression visited a CAM provider once or more during a year, 11.8 % visited psychiatric outpatient services, and 2.5 % visited both. CAM providers were more likely visited by women and by people with higher education. The probability of visiting psychiatric services, and CAM providers and psychiatric services in combination, was strongly associated with more severe symptoms of anxiety/depression, whereas the separate use of CAM providers was not.
CAM provider visits
The CAM provider visit rate of 17.8 % in the current study is not far from a US study (data from 1997 to 98) where 20 % of those with anxiety attacks had visited a CAM provider within the last 12 months . However, our CAM visit rate of 23.9 % among those with severe disease is somewhat higher than the 19.3 % visit rate among patients with severe depression . Another US study (data from 1996) reported that only 9.8 % of those with a mental condition had visited a CAM practitioner , whereas an Australian study (data collected in 2007-08) found that 41.8 % of those with a chronic mental health condition had visited a CAM provider during the previous year . The lower rates in the studies from the 90s conform with the general increased use of CAM providers during the period up to our survey . In addition, a plausible explanation of the difference in visit rates is the inter study variation of definitions and methodology, for instance the inclusion or exclusion of chiropractors as CAM practitioners [6–8, 21]. Differences in availability and access to CAM providers, conventional psychiatric care, and other sources of mental care in different countries, geographical contexts, and health care systems might also influence the differences in CAM visit rates .
We found a higher use of CAM providers among people with anxiety/depression than among the general Tromsø population (12.7 %) , a pattern also observed in other populations . Possible explanations might be easier access and less stigma when visiting CAM providers compared to conventional care [24, 25], the holistic perspective and active patient participation offered by CAM therapists [15, 16], and the higher somatic morbidity among people with mental health problems .
Combined CAM provider and psychiatric specialist visits
Most CAM therapy use seem to be concurrent to the use of conventional treatment [7, 23, 27]. In the present study, only 2.5 % reported visits to both CAM providers and psychiatric services during the previous year. This is a notably low rate compared to the finding by Simon et al that CAM providers were aware of concurrent conventional care for mental health problems in 20–50 % of visits . However, we studied the combination of CAM provider and conventional specialist care, whereas Simon et al also included conventional primary care. Despite these methodological differences, our low rate probably reflects a low access to psychiatric specialist care in Tromsø, Norway, as reported elsewhere . In addition, the low rate might be related to stigma, leading people not to seek care in specialist psychiatric settings [29, 30]. Another possible explanation is that some people with anxiety/depression might be satisfied with care from one provider, whether care is offered by a CAM provider or a mental care specialist.
Use according to gender and education
In the present study, men with anxiety/depression used CAM providers significantly less than women, which is in line with others’ findings . Low use among men might be explained by preconceptions of masculine behaviour in a traditional sense, hindering men from showing their need for help and support . Another explanation is related to the idea that men perceive their body and health as more “mechanical” than women, and that they, therefore, are less attracted to CAM where wholeness, communication and personal relations are more pronounced than biological mechanisms .
Overall, it is reported that CAM therapy users with depressive disorders have a higher level of education than non-users . In line with this, we found that higher educated people more likely visited CAM providers. However, this contrasts findings of no such association in general populations in Norway [14, 33, 34], but conforms with most international studies . It is believed that higher education increases the perception of mental problems and the willingness to seek care . People with higher education might also be more able to find relevant information about CAM, and to afford such treatment .
There were no statistically significant associations between gender and education on the one hand, and the combined use of CAM providers and psychiatric specialist services on the other. This confirms with our previous study regarding use of psychiatric specialist services among people with anxiety/depression .
The current findings regarding age and household income are discussed elsewhere [14, 28].
Use according to severity of disease
People with moderate anxiety/depression used CAM providers more than they used psychiatric specialists, whereas we found the opposite regarding people with severe disease. Still, less than half of those with severe anxiety/depression visited psychiatric specialist services during a year. Results regarding visits to psychiatric specialist services are discussed elsewhere .
In the group with severe anxiety/depression, 13 % visited both a CAM provider and psychiatric specialist services, and the probability of visiting was 7.53 times higher than among those with moderate disease. The severe sufferers thus seem to use CAM providers and conventional care additionally. The higher use of both services in patients reporting more severe depression is in line with Adams et al , but in contrast to Druss et al who found no difference regarding the degree of mental health problems .
Only 2.2 % of those reporting moderate anxiety/depression used combined care. This might be due to the overall lower use of both CAM and conventional care in the current study. Other reasons could be that people with moderate disease would avoid seeking help from conventional psychiatric services due to fear of stigma and feelings of guilt and shame , and also that CAM providers might be a substitute or an alternative pathway when access to conventional care is limited [39, 40]. On the other hand, those who report moderate ailments might be satisfied with CAM provider treatment alone. The line between prevention and treatment might be intertwined in many of these cases. A low threshold CAM service could be a proper supplement for some with minor morbidity, seeking to prevent worsening of symptoms.
Summing up, one might say that psychiatric specialist services seems to be reserved for those with the most severe disease, in keeping with the guidelines that specialist care should treat the sickest, and that moderate ailments to a greater extent are treated elsewhere. However, our findings add to a solid documentation that the use of mental health services both in general populations and in people with anxiety/depression in high income countries is limited, indicating that these symptoms are undertreated [2, 41, 42].
Strengths and limitations
Particular strengths of this study were the large sample size, the high response rate, and the comprehensive coverage of information about health, disease, and socio-economic status in the questionnaires.
Nevertheless, the study should be interpreted in light of some limitations. Despite a high baseline response rate, our sample may not be entirely representative of the population suffering from anxiety/depression, as it is well known that women, healthier persons, and higher socio-economic groups are more likely to participate in population surveys . In Tromsø 6, attendees were older, and the proportion women were higher than in non-attendees [44, 45]. In the second Tromsø Study (1979-80) the participation of people with psychiatric morbidity was approximately 20 % lower than for those without such morbidity , and lower participation is likely the case for Tromsø 6 as well. However, this applies particularly to serious psychiatric morbidity [20, 46].
Additionally, our data might underestimate psychiatric morbidity and treatment seeking due to perceived stigma , and treatment seeking might also be underestimated in the population since questions about psychiatric conditions and use of services were spread throughout the questionnaire, probably increasing inaccuracies . However, there is hardly any reason why people should report anxiety/depression but not use of CAM providers and psychiatric services, thus the relative validity between these variables should be quite robust.
The validity of self-reported data as such may be questioned, although agreement between self-reported and registered health care utilisation is generally high . It might also be easier to report anxiety/depression in a self-administered questionnaire than reporting to health care providers. Moreover, self-reported anxiety/depression might be the best available measure for our study purpose, since research based on doctor made diagnoses would make it difficult to include the non-visitors.
Our analyses focused on anxiety/depression, but we cannot rule out the possibility that participants may have had other psychiatric and/or somatic ailments or diseases in addition, because the reasons for visiting were not reported.
Furthermore, it might be a problem that we asked about anxiety/depression at the time of the survey, whereas health care utilisation was reported for the previous 12 months. However, the onset of these diseases is often ahead of 30 years of age [3, 4], making it unlikely that this have affected our study.
Finally, we cannot exclude the possibility of unmeasured confounders of the reported associations.