Abstract Objectives There is no clear evidence about the association between socioeconomic status (SES) and mental health services (MHS) use. Those with lower SES may be less prone to recognize they need MHS, but they may access free health services. This study aims to assess the link between SES, needs perception and affordability of MHS, among depressed persons. Methods Data from the 2019 Portuguese National Health Survey were used. Among those depressed (N = 3,807; Personal Health Questionnaire-8 ≥ 5), we used gender-stratified logistic regressions to model perception of need and affordability (unfulfilled MHS needs due to financial constraints), as a function of education and income quintile, adjusting for age group and marital status. Health insurance was used as a mediation variable. Results Compared to low education, high-educated men lad lower perception of need (17.2%, OR = 0.46, 95%CI=0.44-0.47) and high-educated women had higher (31.3%, OR = 1.06, 95%CI=1.04-1.07). Men in the first income quintile were more likely to recognize need (34.2%, OR = 1.26, 95%CI=1.23-1.29). Among those with self-reported needs, affordability constraints were more likely among men with higher education (61.9%, OR = 16.9, 95%CI=16.0-18.0), and less-likely among high-educated women (24.2%, OR = 0.88, 95%CI=0.86-0.91). Those in the poorest income quintile were more likely to report affordability concerns (66.5%, OR = 16.3, 95%CI=15.4-17.3 among men; 51.5%, OR = 4.66, 95%CI=4.51-4.81 among women). After adjusting for health insurance, the disadvantage of those in the poorest income quintile decreased among men (OR = 14.9, 95%CI=14.1-15.8) and increased among women (OR = 5.00, 95%CI=4.84-5.17). Conclusions High-educated men seem more likely to report low perceived need and affordability concerns. Low-income individuals' concerns about affordability question universal mental healthcare and may contribute to wider health inequalities. Key messages High-educated men seem more likely to report low perceived need and affordability concerns. Affordability concerns are more likely among low-income men and women. That questions universal mental healthcare and may contribute to wider health inequalities.
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