The increase in the divorce rate has received a great deal of scientific attention. Most research has focused on the consequences of divorce or separation for ex-partners and their children. The health consequences of divorce are also well documented, showing the detrimental effects of divorce on both somatic [1–5] and mental health [2, 6–9], with the divorced or separated experiencing higher levels of depression, stress, and fear, as well as lower levels of self-esteem [10–20]. However, little is known about how these adverse mental health consequences translate into the use of health care services. A few existing studies have indicated that mental health care use and health care use in general is higher among the divorced or separated than among the married or cohabiting, regardless of mental health status [21–24]. Compared to the married or cohabiting, the divorced or separated visit professional health care providers like general practitioners , specialists , and psychiatrists  more often, and are also hospitalized more often [21, 25]. Single mothers seem to suffer the most; they have more health problems and turn to professional mental health services more frequently [26–29]. Moreover, Dutch research has indicated that the divorced or separated not only have higher rates of mental health care use, they also have higher rates of unmet need. This means that they are more often in a situation in which they have mental health care needs but do not receive sufficient care . On the other hand, for a subgroup of single mothers, a Canadian study found that the higher use of professionals for mental health reasons reflected their higher rates of psychopathology . Apart from Bijl and Ravelli's study , the aforementioned studies were not based on a representative sample of the general population, did not adjust for important intermediary variables or confounders like socioeconomic status and the availability of informal support , or did not include data on anyone other than women . Furthermore, existing studies have focused only on a single country--the United States of America , the Netherlands , Canada [29, 31], or the United Kingdom . Moreover, only two studies [25, 30] have focused on care seeking for mental health problems. In this study, we examine whether there are differences between the divorced and the married in professional care seeking due to mental health problems, using a representative sample of the population of 29 European countries. Based on Andersen's Behavioral Model , we are able to identify some social structural determinants that explain these individual differences in mental health care consumption at both the individual and the country level. Andersen's Behavioral Model asserts that the consumption of medical care depends on the presence of predisposing characteristics, enabling resources, and need factors.
Predisposing characteristics are those features that are present before the development of a mental health problem. We consider household composition, education, work status, age, and gender to be relevant predisposing features.
The predisposing characteristic that is our main interest is household composition--more specifically, marital status. A few studies that exist show that different family compositions are associated with different amounts of health care use [25, 33] and demonstrate that there is a higher mental health care consumption among the divorced or separated than the married or cohabiting [21–23, 34]. Another relevant aspect of household composition is the presence of children. Because divorced parents are forced to maintain contact with each other, the presence of children in the household may have an impact on their mental health. In addition, having sole custody of children often involves parenting strain and financial costs, making it more difficult to find a job, make new friends, or find a new partner [35–37], all of which act as important buffers against mental health problems (e.g., ). On the other hand, children may add a sense of meaning to parents' lives, and older children in particular may be an important source of practical and social support for their parents [38, 39].
Educational level also affects the amount of mental health care consumption sought. Even after controlling for mental health status, the lower educated are less inclined to turn to professional mental health care services . Previous research has indicated that divorce is more common among the highly educated , which may explain the higher mental health care use among the divorced. Recently, however, some authors [41, 42] have argued that in countries where the cost of divorce has decreased, the lower educated are more at risk of divorce, undermining that explanation.
Work status also correlates with the use of mental health care: compared to working people, people outside of the labor market, like the unemployed, the retired, and housewives and househusbands, are found to be less inclined to seek professional care because of mental health problems [24, 43], even after mental health status is controlled for. Consequently, since divorced people have an increased risk of being laid off [44, 45], we could expect them to seek professional mental health care less often.
With regard to age, the risk of illness increases with age and, consequently, health care consumption expands [43, 46].
Research has also shown that women have higher health care utilization rates than men [24, 46, 47]. Some research indicates that this is largely explained by the existence of gender differences in mental health regardless of marital status . Some researchers assert that being divorced or separated has a more severe impact on the mental health of women than of men [12, 48], which may explain higher mental health care consumption by divorced women. Others explain these gender differences in service use by pointing out that women are generally found to be more inclined to seek professional help, even after their actual need is controlled for . According to these researchers, the impact of marital status on mental health care consumption might therefore differ by gender, with women having a higher mental health care use rate than men.
Enabling resources are the means and knowledge needed to acquire care. To receive care, one has to possess both financial means and the knowledge of where to go to seek help. In Europe, the wealthy are more likely to seek out specialist care, while access to primary care seems to be pro-poor or equal for all income groups, even after controlling for need [50, 51]. In addition, social support from relatives and friends can be considered an enabling resource. On the one hand, social support can encourage health care use, as social networks may help with the recognition of the development of health problems and may stimulate a person to seek professional care [32, 52–54]. On the other hand, social support may also impede health care consumption. Individuals experiencing problems usually turn to their immediate environment for help before contacting formal care services. However, as individuals with low levels of social support cannot rely on the help of their acquaintances, asking for professional care can be a way to compensate for a lack of social support [32, 55]. Compared to the married and cohabiting, the divorced have smaller social networks and less social support available to them . In addition to the loss of their former partner, they also lose half of their relatives and, often, some shared friends . We therefore expect the divorced to have higher mental health care use due to less available social support.
Need factors include health status and the perceived need for help [21, 32]. On average, the divorced, compared to the married, have worse somatic [2, 4, 5, 21] and mental health statuses. They experience higher levels of distress, depression, and anxiety [2, 6, 7], and have to deal with certain somatic problems more frequently , often putting an extra burden on their mental health. The differences in mental and physical health can be largely--but not completely--explained by a socioeconomic situation that is worse and by a lack of social support [2, 3, 57]. Other explanations are health selection effects--healthier individuals are less likely to divorce [2, 4, 58], the damaging effects of the stigmatization of divorce, and the occurrence of negative life events as a consequence of divorce, for example, having to move . Thus, the higher health care consumption of the divorced may be in large part a consequence of worse physical and/or mental health. However, even after controlling for these need factors, previous research indicates that the mental health care consumption rate of the divorced seems to remain higher than that of the married [21, 25]. Moreover, persons without a partner express higher unmet care needs than those living with a partner .
To control for between-country differences in the distribution of our key variables--marital status and professional care consumption--we consider two country-level indicators, the country-level divorce rates and the supply of professional care.
We expect to see differences between countries in the use of mental health services on the basis of marital status, because norms and values about family and divorce as well as social policies about marital dissolution and sole parenthood vary between countries . At present, there is insufficient research on the link between the divorce rate and marital status differences as they relate to mental health service use. However, we see two possible ways in which the divorce rate might interact with the relation between marital status and mental health services use. First, we expect to find that higher divorce rates go hand in hand with an enhanced professional service use by the divorced. Although more subtle forms of stigmatization are still possible , one can expect divorce to be less stigmatized in countries where the divorce rate is higher , making it easier for the divorced to seek help . Second, there are indications that the use of professional care among the divorced could actually be lower in countries with a high divorce rate. On the basis of social comparison theory  and of research on divorce and stigma , we can assume that people in high-divorce countries will no longer view marital dissolution as different or problematic [7, 63–65], resulting in a relative decline in professional care seeking among the divorced. Of course, it is also possible that the divorce rate has no effect on professional care consumption beyond the compositional effects that result from the marital status composition of the population.
The availability of mental health services may also influence utilization . We expect that the use of professional mental health care will be greater in countries where help is available and accessible. According to Wang et al. , unmet need is worse in low- and middle-income countries, and the treatment gap may therefore be attributable to the reduced amount these nations have to spend on mental health care from health budgets that are already overburdened . Consequently, we can expect cross-national variation in the availability of mental health services to influence utilization, even among middle- and high-income European countries. Hence, the availability of general or more specialized professionals is a supply-side factor that should not be ignored  and that could be incorporated into Andersen's model as an important enabling factor at the supra-individual level. Country-level indicators are unable to accommodate important within-country differences in the availability of mental health services. In order to consider these within-country differences, we also include the degree of urbanization in the area of residence as a rough indicator of the availability of more specialized mental health professionals . Differences between rural and urban areas may also signal differences in stigma beliefs. For instance, as Hoyt and colleagues  have shown, in the rural areas of the United States a reluctance to seek professional help is closely linked to stigmatizing beliefs about mental health care.
In sum, we will first examine whether a difference exists between the married or cohabiting and the divorced or separated in their use of professional health care for emotional or psychological problems. Second, we will try to uncover some predisposing, enabling, and need factors that explain this possible difference in amount of use. Finally, we intend to examine between-country variation by introducing country characteristics--divorce rate and the supply of services--into the analysis.