No utilization without subjective need – a mixed-methods study on guideline-compliant mental health care for individuals with depressive symptoms

Abstract Background The reasons why individuals with depressive disorders do not seek professional help are multifaceted and include illness-related, attitudinal, and structural barriers. While subjective need can facilitate help-seeking, its absence may act as a barrier. However, treatment guidelines primarily rely on objective need, defined by diagnosis, and do not address potential discrepancies between objective and subjective need. This study aimed to examine the frequency of congruent and incongruent mental health service use and to explore the conditions and reasons underlying incongruence between objective need, subjective need, and service use. Methods This mixed-methods study used a sequential explanatory design based on a population-based sample of individuals with at least mild depressive symptoms (PHQ-9 ≥ 5). Quantitative data from telephone interviews conducted at baseline (T0) and 12 months later (T1) were used to assess objective need, subjective need, and mental health service use, and to determine whether service use was congruent or incongruent with guideline recommendations. Participants with different need-use patterns were then selected through theoretical sampling for subsequent qualitative interviews exploring the conditions and reasons underlying these patterns. Further cases were selected to refine, elaborate, or challenge categories developed through the Grounded Theory analysis according to Corbin and Strauss. Results The analysis sample for descriptive analyses comprised 456 participants. Both the quantitative and qualitative data indicate that subjective need is a key predictor of help-seeking behavior. Seeking professional help in the absence of a perceived need is highly unlikely. Qualitative findings ( n = 23) suggest that a dichotomous classification of subjective need (yes/no) is too simplistic and does not adequately reflect the reality of mental health care utilization. A typology of subjective need was therefore developed, identifying six types. Conclusions This typology offers a framework for tailoring care more precisely to individuals’ perceived need. Our findings highlight the importance of considering subjective and objective need in parallel when evaluating service utilization, particularly in cases of incongruence. This requires a shift from a predominantly objective need-based approach toward a more comprehensive perspective that considers both subjective and objective need alongside barriers, prior treatment experiences, social support, and coping strategies.