Authors

Ronald C Kessler , Alan E Kazdin , Sergio Aguilar-Gaxiola , Ali Al-Hamzawi , Jordi Alonso , Yasmin A Altwaijri , Laura H Andrade , Corina Benjet , Chrianna Bharat , Guilherme Borges , Ronny Bruffaerts, Brendan Bunting, José Miguel Caldas de Almeida, Graça Cardoso, Wai Tat Chiu , Alfredo Cía, Marius Ciutan, Louisa Degenhardt , Giovanni de Girolamo, Peter de Jonge, Ymkje Anna de Vries, Silvia Florescu, Oye Gureje, Josep Maria Haro, Meredith G Harris, Chiyi Hu, Aimee N Karam, Elie G Karam, Georges Karam, Norito Kawakami, Andrzej Kiejna, Viviane Kovess-Masfety, Sing Lee, Victor Makanjuola, John J McGrath, Maria Elena Medina-Mora , Jacek Moskalewicz, Fernando Navarro-Mateu, Andrew A Nierenberg, Daisuke Nishi, Akin Ojagbemi, Bibilola D Oladeji, Siobhan O'Neill, José Posada-Villa, Victor Puac-Polanco , Charlene Rapsey, Ayelet Meron Ruscio, Nancy A Sampson , Kate M Scott, Tim Slade, Juan Carlos Stagnaro, Dan J Stein, Hisateru Tachimori, Margreet Ten Have, Yolanda Torres, Maria Carmen Viana, Daniel V Vigo, David R Williams, Bogdan Wojtyniak, Miguel Xavier, Zahari Zarkov, Hannah N Ziobrowski,; WHO World Mental Health Survey collaborators

Abstract

Patient-reported helpfulness of treatment is an important indicator of quality in patient-centered care. We examined its pathways and predictors among respondents to household surveys who reported ever receiving treatment for major depression, generalized anxiety disorder, social phobia, specific phobia, post-traumatic stress disorder, bipolar disorder, or alcohol use disorder. Data came from 30 community epidemiological surveys - 17 in high-income countries (HICs) and 13 in low- and middle-income countries (LMICs) - carried out as part of the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Respondents were asked whether treatment of each disorder was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Across all surveys and diagnostic categories, 26.1% of patients (N=10,035) reported being helped by the very first professional they saw. Persisting to a second professional after a first unhelpful treatment brought the cumulative probability of receiving helpful treatment to 51.2%. If patients persisted with up through eight professionals, the cumulative probability rose to 90.6%. However, only an estimated 22.8% of patients would have persisted in seeing these many professionals after repeatedly receiving treatments they considered not helpful. Although the proportion of individuals with disorders who sought treatment was higher and they were more persistent in HICs than LMICs, proportional helpfulness among treated cases was no different between HICs and LMICs. A wide range of predictors of perceived treatment helpfulness were found, some of them consistent across diagnostic categories and others unique to specific disorders. These results provide novel information about patient evaluations of treatment across diagnoses and countries varying in income level, and suggest that a critical issue in improving the quality of care for mental disorders should be fostering persistence in professional help-seeking if earlier treatments are not helpful.

Methods 

The World Health Organization (WHO)’s World Mental Health (WMH) Surveys are a coordinated set of community epidemiological surveys administered to probability samples of the noninstitutionalized household population in countries throughout the world16. Data for the present study come from 30 WMH surveys (Table 1). Seventeen surveys were carried out in countries classified by the World Bank as HICs (Argentina, Australia, Belgium, France, Germany, Israel, Italy, Japan, The Netherlands, New Zealand, Northern Ireland, Poland, Portugal, Saudi Arabia, the US, and two in Spain). The other thirteen surveys were conducted in countries classified as LMICs (Brazil, Iraq, Lebanon, Mexico, Nigeria, Peru, People’s Republic of China, Romania, South Africa, and two each in Bulgaria and Colombia). Twenty of these 30 surveys were based on nationally representative samples (14 in HICs, 6 in LMICs), three on samples of all urbanized areas in the country (Argentina, Colombia, Mexico), three on samples of selected states (Nigeria) or metropolitan areas (Japan, Peru), and four on samples of single states (Murcia, Spain) or metropolitan areas (Sao Paolo, Brazil; Medellin, Colombia; Shenzhen, People’s Republic of China). Response rates ranged from 45.9% (France) to 97.2% (Medellin, Colombia) and averaged 68.9% across surveys.

Measures

The interview schedule used in the WMH surveys was the WHO Composite International Diagnostic Interview (CIDI) Version 3.017, a fully structured diagnostic interview designed to be used by trained lay interviewers. A standardized seven-day training program was given to all WMH interviewers across countries. The program culminated in an examination that had to be passed before the interviewer could be authorized to participate in data collection18. The interview schedule was developed in English and translated into other languages using a standardized WHO translation protocol19. Interviews were administered face-to-face in respondents’ homes after obtaining informed consent using procedures approved by local institutional review boards. Interviews were in two parts. Part I was administered to all respondents and assessed core DSM-IV mental disorders (N=146,411 respondents across all surveys). Part II assessed additional disorders and correlates and was administered to 100% of respondents who met lifetime criteria for any Part I disorder plus a probability subsample of other Part I respondents (N=80,841).

Results

Disorder prevalence, treatment, and patient-reported treatment helpfulness The lifetime disorder prevalence in the total sample ranged from a high of 9.5% for alcohol use disorder (11.5% in HICs; 6.7% in LMICs) to a low of 1.2% for major depressive episode in bipolar disorder (1.3% in HICs; 0.9% in LMICs). The prevalence was consistently higher in HICs than LMICs (X2 1 =10.8-398.0, p=0.001 to <0.001) (Table 2). Roughly one-fourth (23.0%) of respondents stacked across diagnostic categories received treatment, but this proportion was nearly twice as high in HICs as LMICs (27.1% vs. 13.8%, X2 1 =382.4, p<0.001). The proportion receiving treatment also varied significantly across diagnostic categories, both in the total sample (X2 7 =1402.0, p<0.001) and in the country income group sub-samples (X2 7 =1308.6, p<0.001 in HICs; X2 7 =230.4, p<0.001 in LMICs). This variation was very similar in HICs and LMICs (Pearson correlation=.88), although consistently higher in HICs than LMICs (X2 1 =7.1-261.0, p=0.008 to <0.001), from a high of 43.9% (47.9% in HICs; 31.9% in LMICs) for major depressive episode in bipolar disorder to a low of 11.8% (14.2% in HICs; 6.4% in LMICs) for alcohol use disorder.

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