Elsevier

The Lancet

Volume 370, Issue 9590, 8–14 September 2007, Pages 841-850
The Lancet

Articles
Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys

https://doi.org/10.1016/S0140-6736(07)61414-7Get rights and content

Summary

Background

Mental disorders are major causes of disability worldwide, including in the low-income and middle-income countries least able to bear such burdens. We describe mental health care in 17 countries participating in the WHO world mental health (WMH) survey initiative and examine unmet needs for treatment.

Methods

Face-to-face household surveys were undertaken with 84 850 community adult respondents in low-income or middle-income (Colombia, Lebanon, Mexico, Nigeria, China, South Africa, Ukraine) and high-income countries (Belgium, France, Germany, Israel, Italy, Japan, Netherlands, New Zealand, Spain, USA). Prevalence and severity of mental disorders over 12 months, and mental health service use, were assessed with the WMH composite international diagnostic interview. Logistic regression analysis was used to study sociodemographic predictors of receiving any 12-month services.

Findings

The number of respondents using any 12-month mental health services (57 [2%; Nigeria] to 1477 [18%; USA]) was generally lower in developing than in developed countries, and the proportion receiving services tended to correspond to countries' percentages of gross domestic product spent on health care. Although seriousness of disorder was related to service use, only five (11%; China) to 46 (61%; Belgium) of patients with severe disorders received any care in the previous year. General medical sectors were the largest sources of mental health services. For respondents initiating treatments, 152 (70%; Germany) to 129 (95%; Italy) received any follow-up care, and one (10%; Nigeria) to 113 (42%; France) received treatments meeting minimum standards for adequacy. Patients who were male, married, less-educated, and at the extremes of age or income were treated less.

Interpretation

Unmet needs for mental health treatment are pervasive and especially concerning in less-developed countries. Alleviation of these unmet needs will require expansion and optimum allocation of treatment resources.

Introduction

Neuropsychiatric disorders are the leading causes of disability worldwide, accounting for 37% of all healthy life years lost through disease. They are the most disabling disorders even in low-income and middle-income countries, which can be least able to bear such burdens.1 Although effective and tolerable treatments are increasingly available, even economically advantaged societies have competing priorities and budgetary constraints.2 Knowledge of how to provide effective mental health care has become imperative worldwide.3 Unfortunately, most countries have insufficient data to guide decisions, absent or competing visions for resources, and near constant pressures to cut insurance and entitlements.4

How can countries redesign their mental health care systems and best allocate resources? A first step is documentation of services being used and the extent and nature of unmet needs for treatment. A second step could be to do a cross-national comparison of service use and unmet needs in countries with different mental health care systems. Such comparisons can help to uncover optimum financing, national policies, and delivery systems for mental health care. Unfortunately, few cross-national studies are available.5, 6

For these reasons, WHO established the world mental health (WMH) survey initiative in 1998.7 Coordinated surveys on mental disorders, their severity, impairments, and treatments have been implemented in 28 developing and developed countries. We assessed the frequency, types, and adequacy of mental health service use in 17 countries in which WMH surveys are complete. We also examined unmet needs for treatment in strata defined by the seriousness of mental disorders. Finally, we identified sociodemographic correlates of unmet needs for treatment to guide design and targeting of future resources, policies, and interventions.

Section snippets

Survey respondents

WMH surveys were done in Africa (Nigeria, South Africa), the Americas (Colombia, Mexico, USA), Asia and the Pacific (Japan, New Zealand, Beijing and Shanghai in the Peoples Republic of China), Europe (Belgium, France, Germany, Italy, Netherlands, Spain, Ukraine), and the middle east (Israel, Lebanon).7 Countries were classified with World Bank criteria8 as low-income (Nigeria), lower middle-income (China, Columbia, South Africa, Ukraine), higher middle-income (Lebanon, Mexico), and high-income

Results

Respondents using any mental health services in the previous 12 months varied significantly, with generally fewer services used in low-income or middle-income countries than in high-income countries (table 2). The proportions receiving services also tended to correspond to countries' overall spending on health care (table 1).17 Most respondents used general medical, followed by mental health specialty sectors (with the exceptions of Mexico, Columbia, and Israel, where this trend was reversed);

Discussion

We have shown that the proportion of respondents using 12-month mental health services was generally lower in resource-poor settings than in developed countries, and the proportion receiving services tended to correspond with countries' overall spending on health care. More respondents used general medical sectors than mental health specialty sectors. There were significant relations between disorder severity and probability of service use in almost all countries. However, few of those with

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