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Background The COVID-19 pandemic and subsequent restrictions increased the psychological distress of the population while the use of on-site mental health care decreased. The provision of online mental health care was therefore scaled up in many European countries. The extent to which online care can deliver services to all people (horizontal equity) according to their needs (vertical equity) is unknown. This study assessed whether online advice-seeking was related to mental health needs and whether different population subgroups were equally likely to seek advice. Methods A longitudinal, online survey was carried out in Belgium in April, June, and November 2020. 13,150 different individuals participated in at least one study wave. At the end of each wave, information on how to receive help was provided. Psychological distress was measured using the GHQ-12. We used logistic regression to compare the association between psychological distress and online advice-seeking across waves and sociodemographic groups. Results 29% of the respondents sought online advice in April, and one fifth in June and November. The frequency of advice-seeking was associated with higher psychological distress (OR = 1.24, 95% CI:1.22–1.26). Women, young people, respondents with higher education, and respondents with less social support were more likely to seek advice online. Conclusions Online mental health advice seems to achieve vertical equity. Sociodemographic variables were, however, better predictors of psychological distress than advice-seeking. More attention should be paid to older and less well educated men, who were less likely to seek advice. In the longer term, the responsiveness of online services needs to be assessed.

Background Life satisfaction (LS) is a key indicator of positive mental health and general wellbeing. While its individual predictors are well-documented, less is known about how multiple social categories interplay to shape inequalities. This study applies an intersectional perspective to examine how age, sex and subjective social status (SSS) jointly influence LS. Methods Data were drawn from the March 2025 wave of BELHEALTH, a cohort study of the Belgian population (18+, N = 6,122). LS was self-rated on a scale from 0 to 10. We used Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to assess intersectional inequalities across 24 strata defined by the combination of sex (male/female), SSS (low/middle/high, based on the MacArthur scale) and age group (18-29, 30-49, 50-64, 65+). Results Inequality between strata explained 19.6% of the total variance in LS. Most of this variance (95.9%) was attributable to additive effects of sex, SSS and age. A difference of over two points separated the highest-scoring group (males, high SSS, 65+: predicted LS score = 8.26) from the lowest (males, low SSS, age 50-64: 6.02). Among individuals with low SSS, males reported lower LS than females, especially among the 50-64 age group (6.02; 95% CI: 5.86-6.19 vs. 6.34; 95% CI: 6.22-6.46). LS was highest among older adults (65+) across all SSS levels. Older adults with middle SSS (7.65-7.66) even reported LS levels comparable to younger people with high SSS (7.50-7.80). Conclusions The MAIHDA approach revealed large heterogeneity in LS, particularly within the low SSS group, where middle-aged men (50-64) scored lower than women. No sex differences were observed within the middle and high SSS groups. These findings demonstrate the value of intersectional analysis in uncovering inequalities that may be missed when examining social categories separately. Future research should explore potential gendered patterns in how men and women self-report life satisfaction. Key messages • Life satisfaction was lowest among middle-aged men with low subjective social status. Older adults (65+) reported higher scores than their younger counterparts across all social status levels. • Intersectional analysis reveals disparities in life satisfaction that would be overlooked using traditional approaches.

Background Cross-sectional data from the Belgian Health Interview Survey have documented higher levels of psychological distress among non-European and second-generation migrants compared to native Belgians. Previous research has widely recognised discrimination as a key social determinant that negatively impacts mental health within migrant populations. However, limited research has explored how this association evolves over time. This longitudinal study examines trends in anxiety and depression among first- and second-generation migrants, and those who identify with discriminated groups. Methods We used data from three waves of the BELHEALTH cohort, collected online in September 2022, March 2024, and March 2025, among 7,352 Belgian residents aged 18+. Mental health symptoms were assessed using the GAD-7 and PHQ-9. Participants were grouped into five categories: native Belgians, European (Eu) migrants, non-Eu migrants, second-generation Eu migrants and second-generation non-Eu migrants. Respondents also indicated whether they were part of a group that they felt was discriminated, based on their ethnicity, skin colour, religion, nationality or language. Mixed linear models were used to compare mental health outcomes across categories between 2022 and 2025. Results Second-generation non-European migrants showed a significantly higher risk of developing anxiety (β = 0.67, CI95% 0.03;1.32) and depression (β = 1.1, CI95% 0.4;1.8) vs. non-migrants, though this became non-significant after adjusting for age, sex and education (F = 2.2, p = 0.07). However, discrimination based on ethnic background significantly increased the likelihood of anxiety (β = 1.7 CI95% 0.9;2.4) and depression (β = 2.0 CI95% 1.2;2.8) over time, even after adjustment. Conclusions Perceived discrimination was a stronger predictor of anxiety and depression than migration status alone. Tackling discrimination is essential to improving mental health conditions of the migrant population in Belgium. Key messages • Ethnic discrimination, more than migration status per se, is a key predictor of anxiety and depression over time in Belgium. • Reducing ethnic discrimination is essential to improving mental health among the migrant population in Belgium.

Longitudinal studies have identified an increase in psychological distress across the general population during the COVID-19 pandemic. Nevertheless, the trajectories of mental health outcomes exhibit variations, suggesting potential associations with psychosocial individual factors. This paper identifies the factors of this individual trajectory of psychological distress during the COVID-19 pandemic. Five waves of a prospective cohort survey were conducted with a convenience sample of the general population in Belgium between March 2020 and November 2021 (n = 4,550). Psychological distress was measured using the GHQ-12. Individual covariates included socioeconomic factors (age, gender, level of education), psychological factors (loneliness, social support, and social activities), and factors related to the virus and the lockdown measures (exposure to COVID-19 and survey wave). Multilevel models were used for analysis. Women and young people experienced more pronounced fluctuations in their risk of psychological distress across study waves, experiencing both increases and decreases. We found that individual variance in psychological distress breaks down into two components, respectively 43% for psychosocial factors (time-invariant) and 57% for the survey waves (time-variant) variation. A significant share of the time-invariant difference in psychological distress over COVID-19 is associated with loneliness, social support, and social activities. Loneliness emerged as the most important interpersonal factor associated with psychological distress. The change in psychological distress was mainly associated with psychosocial factors rather than with pandemic-related dynamics (e.g. survey waves). These findings suggest that mitigation policies aiming at controlling the pandemic should focus more on addressing specific individual vulnerabilities rather than solely responding to the fluctuations within pandemic waves to decrease their detrimental impact on mental health.

Background Patients with a migration background (MB) have more mental health disorders than those without migration background. Yet, those patients are still underrepresented in mental healthcare services and have more unmet medical needs. Although providers’ bias has been well studied, up to date, little is still known about the factors explaining those biases. We assessed the effect of general practitioners’ (GPs') individual and organizational factors on their decision-making regarding diagnosis, treatment and referral recommendations for patient with MB with symptoms of major depression. Methods An experimental study staged a video-vignette of a depressed patient with or without MB. GPs had to make decision about diagnosis, treatment and referral. We then assessed the influence of several factors on their decisions such as age, ethnicity, workload and patient confidence. ANOVA and MANOVA were used for analyses. Results Overall, we found more unfavourable decisions in GPs diagnosis and treatment recommendations regarding the patient with a MB (F = 3.56, p < 0.001). In addition, they considered the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and would prescribe less often a medical treatment to these patients (F = 4.09, p < 0.05). Nevertheless, few factors explained these differences, except the age, the workload and the patient trustworthiness. Conclusions This paper highlighted GPs biases based on apparent migration background of a patient with major depression that perpetuates ethnic inequalities in mental health care. Further research into the origins of discrimination in primary mental health care are needed to explain how and when those discriminations arise. Key messages • This paper shed light on pervasive unintentional discrimination still persist in mental health care among migrants in Europe. • These findings may help us to further understand the role of general practitioner behaviour in primary mental health care discrimination.