Hostname: page-component-7d684dbfc8-w65q4 Total loading time: 0 Render date: 2023-09-27T05:54:34.967Z Has data issue: false Feature Flags: { "corePageComponentGetUserInfoFromSharedSession": true, "coreDisableEcommerce": false, "coreDisableSocialShare": false, "coreDisableEcommerceForArticlePurchase": false, "coreDisableEcommerceForBookPurchase": false, "coreDisableEcommerceForElementPurchase": false, "coreUseNewShare": true, "useRatesEcommerce": true } hasContentIssue false

Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder

Published online by Cambridge University Press:  20 October 2020

Daniel Vigo*
Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
Josep Maria Haro
Parc Sanitari Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain
Irving Hwang
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
Sergio Aguilar-Gaxiola
Center for Reducing Health Disparities, UC Davis Health System, Sacramento, California, USA
Jordi Alonso
Health Services Research Unit, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain Pompeu Fabra University (UPF), Barcelona, Spain
Guilherme Borges
National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
Ronny Bruffaerts
Universitair Psychiatrisch Centrum – Katholieke Universiteit Leuven (UPC-KUL), Campus Gasthuisberg, Leuven, Belgium
Jose Miguel Caldas-de-Almeida
Lisbon Institute of Global Mental Health and Chronic Diseases Research Center (CEDOC), NOVA Medical School | Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
Giovanni de Girolamo
IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
Silvia Florescu
National School of Public Health, Management and Development, Bucharest, Romania
Oye Gureje
Department of Psychiatry, University College Hospital, Ibadan, Nigeria
Elie Karam
Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University, Beirut, Lebanon Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Beirut, Lebanon Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon
Georges Karam
Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University, Beirut, Lebanon Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon
Viviane Kovess-Masfety
Ecole des Hautes Etudes en Santé Publique (EHESP), EA 4057, Paris Descartes University, Paris, France
Sing Lee
Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong
Fernando Navarro-Mateu
UDIF-SM, Subdirección General de Planificación, Innovación y Cronicidad, Servicio Murciano de Salud, IMIB-Arrixaca, CIBERESP-Murcia, Murcia, Spain
Akin Ojagbemi
Department of Psychiatry, University of Ibadan, Nigeria
Jose Posada-Villa
Colegio Mayor de Cundinamarca University, Faculty of Social Sciences, Bogota, Colombia
Nancy A. Sampson
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
Kate Scott
Department of Psychological Medicine, University of Otago, Dunedin, Otago, New Zealand
Juan Carlos Stagnaro
Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Universidad de Buenos Aires, Argentina
Margreet ten Have
Trimbos-Instituut, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
Maria Carmen Viana
Department of Social Medicine, Postgraduate Program in Public Health, Federal University of Espírito Santo, Vitoria, Brazil
Chi-Shin Wu
Department of Psychiatry, National Taiwan University Hospital & College of Medicine, Taipei, Taiwan
Somnath Chatterji
Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
Pim Cuijpers
Department of Clinical Psychology, VU University, Amsterdam, The Netherlands The Netherlands & EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
Graham Thornicroft
Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
Ronald C. Kessler
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
Author for correspondence: Daniel Vigo, E-mail:



Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.


Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.


MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.


Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.

Original Article
Copyright © The Author(s), 2020. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Alonso, J., Liu, Z., Evans-Lacko, S., Sadikova, E., Sampson, N., Chatterji, S., … Thornicroft, G. (2018). Treatment gap for anxiety disorders is global: Results of the World Mental Health Surveys in 21 countries. Depression and Anxiety, 35(3), 195208. doi: 10.1002/da.22711.CrossRefGoogle ScholarPubMed
American Association for Public Opinion Research. (2016). Standard definitions: Final dispositions of case codes and outcome rates for surveys (9th edition). Oakbrook Terrace, IL: AAPOR.Google Scholar
Amouzou, A., Leslie, H. H., Ram, M., Fox, M., Jiwani, S. S., Requejo, J., … Boerma, T. (2019). Advances in the measurement of coverage for RMNCH and nutrition: From contact to effective coverage. BMJ Global Health, 4(Suppl 4), e001297. doi: 10.1136/bmjgh-2018-001297.CrossRefGoogle ScholarPubMed
Bloom, D. E., Chen, S., & McGovern, M. E. (2018). The economic burden of noncommunicable diseases and mental health conditions: Results for Costa Rica, Jamaica, and Peru. Pan American Journal of Public Health, 42, e18. doi: 10.26633/rpsp.2018.18.Google ScholarPubMed
Boerema, A. M., Ten Have, M., Kleiboer, A., de Graaf, R., Nuyen, J., Cuijpers, P., & Beekman, A. T. F. (2017). Demographic and need factors of early, delayed and no mental health care use in major depression: A prospective study. BMC Psychiatry, 17(1), 367. doi: 10.1186/s12888-017-1531-8.CrossRefGoogle ScholarPubMed
British Columbia Ministry of Mental Health and Addictions. (2019). A pathway to hope: A roadmap for making mental health and addictions care better for people in British Columbia. Victoria, BC: Government of British Columbia. Scholar
Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., & Saxena, S. (2016). Scaling-up treatment of depression and anxiety: A global return on investment analysis. The Lancet. Psychiatry, 3(5), 415424. doi: 10.1016/s2215-0366(16)30024-4.CrossRefGoogle ScholarPubMed
Clark, D. M., Canvin, L., Green, J., Layard, R., Pilling, S., & Janecka, M. (2018). Transparency about the outcomes of mental health services (IAPT approach): An analysis of public data. Lancet (London, England), 391(10121), 679686. doi: 10.1016/s0140-6736(17)32133-5.CrossRefGoogle ScholarPubMed
Clark, D. M., Layard, R., Smithies, R., Richards, D. A., Suckling, R., & Wright, B. (2009). Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, 47(11), 910920. doi: 10.1016/j.brat.2009.07.010.CrossRefGoogle ScholarPubMed
Cramer, J. A., & Rosenheck, R. (1998). Compliance with medication regimens for mental and physical disorders. Psychiatric Services, 49(2), 196201. doi: 10.1176/ps.49.2.196.CrossRefGoogle ScholarPubMed
Degenhardt, L., Glantz, M., Evans-Lacko, S., Sadikova, E., Sampson, N., Thornicroft, G., … Kessler, R. C. (2017). Estimating treatment coverage for people with substance use disorders: An analysis of data from the World Mental Health Surveys. World Psychiatry, 16(3), 299307. doi: 10.1002/wps.20457.CrossRefGoogle ScholarPubMed
Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J. P., … Chatterji, S. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA, 291(21), 25812590. doi: 10.1001/jama.291.21.2581.Google ScholarPubMed
First, M., Spitzer, R., Gibbon, M., & WIlliams, J. (2002). Structured clinical interview for DSM- IV TR axis I disorders, research version, non- patient edition (SCID-I/NP). New York, NY: Biometrics Research, New York State Psychiatric Institute.Google Scholar
Gelenberg, A., Freeman, M. P., Markowitz, J. C., Rosenbaum, J. F., Thase, M. E., Trivedi, M. H., & Van Rhoads, R. S. (2010). Practice guideline for the treatment of patients with major depressive disorder. Washington, DC: American Psychiatric Association. Retrieved from Scholar
General Assembly of the United Nations. (2015). Transforming our world: the 2030 Agenda for Sustainable Development. In Resolution. Retrieved from Scholar
Goetzel, R. Z., Long, S. R., Ozminkowski, R. J., Hawkins, K., Wang, S., & Lynch, W. (2004). Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers. Journal of Occupational and Environmental Medicine, 46(4), 398412. doi: 10.1097/ ScholarPubMed
Harkness, J., Pennell, B., Villar, A., Gebler, N., Aguilar-Gaxiola, S., & Bilgen, I. (2008). Translation procedures and translation assessment in the World Mental Health Survey Initiative. In Kessler, R. C., & Bedirhan, T. B. (Eds.), The WHO world mental health surveys: Global perspectives on the epidemiology of mental disorders (pp. 91113). Cambridge, UK: Cambridge University Press.Google Scholar
Haro, J. M., Arbabzadeh-Bouchez, S., Brugha, T. S., de Girolamo, G., Guyer, M. E., Jin, R., … Kessler, R. C. (2006). Concordance of the Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health surveys. International Journal of Methods in Psychiatric Research, 15(4), 167180. doi: 10.1002/mpr.196.CrossRefGoogle ScholarPubMed
Heeringa, S., Wells, J., Hubbard, F., Mneimneh, Z., Chiu, W., Sampson, N., & Berglund, P. (2008). Sample designs and sampling procedures. In Kessler, R. & Üstün, T. (Eds.), The WHO World Mental Health Surveys: Global perspectives on the epidemiology of mental disorders (pp. 1432). New York, NY: Cambridge University Press.Google Scholar
Jeon-Slaughter, H. (2012). Economic factors in of patients’ nonadherence to antidepressant treatment. Social Psychiatry and Psychiatric Epidemiology, 47(12), 19851998. doi: 10.1007/s00127-012-0497-6.CrossRefGoogle ScholarPubMed
Joshi, R., Alim, M., Kengne, A. P., Jan, S., Maulik, P. K., Peiris, D., & Patel, A. A. (2014). Task shifting for non-communicable disease management in low and middle income countries – a systematic review. PLoS ONE, 9(8), e103754. doi: 10.1371/journal.pone.0103754.CrossRefGoogle ScholarPubMed
Kennedy, S. H., Lam, R. W., McIntyre, R. S., Tourjman, S. V., Bhat, V., Blier, P., … Uher, R. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 3. Pharmacological treatments. Canadian Journal of Psychiatry, 61(9), 540560. doi: 10.1177/0706743716659417.CrossRefGoogle Scholar
Kessler, R. C., & Ustün, T. B. (2004). The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatric Research, 13(2), 93121. doi: 10.1002/mpr.168.CrossRefGoogle Scholar
Larson, E., Vail, D., Mbaruku, G. M., Mbatia, R., & Kruk, M. E. (2017). Beyond utilization: Measuring effective coverage of obstetric care along the quality cascade. International Journal of Quality in Health Care, 29(1), 104110. doi: 10.1093/intqhc/mzw141.Google ScholarPubMed
Lasalvia, A., Zoppei, S., Van Bortel, T., Bonetto, C., Cristofalo, D., Wahlbeck, K., … Thornicroft, G. (2013). Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: A cross-sectional survey. Lancet (London, England), 381(9860), 5562. doi: 10.1016/s0140-6736(12)61379-8.CrossRefGoogle ScholarPubMed
Levy-Bruhl, D., Soucat, A., Osseni, R., Ndiaye, J. M., Dieng, B., De Bethune, X., … Knippenberg, R. (1997). The Bamako Initiative in Benin and Guinea: Improving the effectiveness of primary health care. International Journal of Health Planning and Management, 12(Suppl 1), S4979. doi: 10.1002/(sici)1099-1751(199706)12:1 + <s49::aid-hpm466>;2-g.Google ScholarPubMed
Merikangas, K. R., Jin, R., He, J. P., Kessler, R. C., Lee, S., Sampson, N. A., … Zarkov, Z. (2011). Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Archives of General Psychiatry, 68(3), 241251. doi: 10.1001/archgenpsychiatry.2011.12.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence. (2009). Depression in adults: Recognition and management. Clinical guideline [CG90]. London, UK: Department of Health and Social Care. Scholar
Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353(5), 487497. doi: 10.1056/NEJMra050100.CrossRefGoogle ScholarPubMed
Parikh, S. V., Quilty, L. C., Ravitz, P., Rosenbluth, M., Pavlova, B., Grigoriadis, S., … Uher, R. (2016). Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 2. Psychological treatments. Canadian Journal of Psychiatry, 61(9), 524539. doi: 10.1177/0706743716659418.CrossRefGoogle Scholar
Patel, V., Chisholm, D., Parikh, R., Charlson, F. J., Degenhardt, L., Dua, T., … Whiteford, H. A. (2016). Global priorities for addressing the burden of mental, neurological, and substance use disorders. In Patel, V., Chisholm, D., Dua, T., Laxminarayan, R., & Medina-Mora, M. E. (Eds.), Mental, neurological, and substance use disorders: Disease control priorities (Vol. 4, 3rd ed., pp. 128). Washington, DC: The International Bank for Reconstruction and Development / The World Bank.Google Scholar
Patel, V., Saxena, S., Lund, C., Thornicroft, G., Baingana, F., Bolton, P., … UnÜtzer, J. (2018). The Lancet Commission on global mental health and sustainable development. Lancet (London, England), 392(10157), 15531598. doi: 10.1016/s0140-6736(18)31612-x.CrossRefGoogle ScholarPubMed
Pennell, B., Mneimneh, Z., Bowers, A., Chardoul, S., Wells, J., Viana, M., … He, Y. (2008). Implementation of the World Mental Health Surveys. In Kessler, R. C. & Ustun, T. B. (Eds.), The WHO World Mental Health Surveys: Global perspectives on the epidemiology of mental disorders (pp. 3357). Cambridge, UK: Cambridge University Press.Google Scholar
Research Triangle Institute. (2002). SUDAAN 8.0 [computer program]. Research Triangle Park, NC.Google Scholar
Salomon, J. A., Haagsma, J. A., Davis, A., de Noordhout, C. M., Polinder, S., Havelaar, A. H., … Vos, T. (2015). Disability weights for the Global Burden of Disease 2013 study. Lancet Global Health, 3(11), e712723. doi: 10.1016/s2214-109x(15)00069-8.CrossRefGoogle ScholarPubMed
Sheehan, D. V., Harnett-Sheehan, K., & Raj, B. A. (1996). The measurement of disability. International Clinical Psychopharmacology, 11(Suppl 3), 8995. doi: 10.1097/00004850-199606003-00015.CrossRefGoogle ScholarPubMed
Shigekawa, E., Fix, M., Corbett, G., Roby, D. H., & Coffman, J. (2018). The current state of telehealth evidence: A rapid review. Health Affairs, 37(12), 19751982. doi: 10.1377/hlthaff.2018.05132.CrossRefGoogle ScholarPubMed
Tanahashi, T. (1978). Health service coverage and its evaluation. Bulletin of the World Health Organization, 56(2), 295303.Google ScholarPubMed
Ten Have, M., Nuyen, J., Beekman, A., & de Graaf, R. (2013). Common mental disorder severity and its association with treatment contact and treatment intensity for mental health problems. Psychological Medicine, 43(10), 22032213. doi: 10.1017/s0033291713000135.CrossRefGoogle ScholarPubMed
Thornicroft, G., Brohan, E., Rose, D., Sartorius, N., & Leese, M. (2009). Global pattern of experienced and anticipated discrimination against people with schizophrenia: A cross-sectional survey. Lancet (London, England), 373(9661), 408415. doi: 10.1016/s0140-6736(08)61817-6.CrossRefGoogle ScholarPubMed
Thornicroft, G., Chatterji, S., Evans-Lacko, S., Gruber, M., Sampson, N., Aguilar-Gaxiola, S., … Kessler, R. C. (2017). Undertreatment of people with major depressive disorder in 21 countries. British Journal of Psychiatry, 210(2), 119124. doi: 10.1192/bjp.bp.116.188078.CrossRefGoogle ScholarPubMed
Vigo, D., Kestel, D., Pendakur, K., Thornicroft, G., & Atun, R. (2019). Disease burden and government spending on mental, neurological, and substance use disorders, and self-harm: Cross-sectional, ecological study of health system response in the Americas. Lancet Public Health, 4(2), e89e96. doi: 10.1016/s2468-2667(18)30203-2.CrossRefGoogle ScholarPubMed
Vigo, D., Patel, V., Becker, A., Bloom, D., Yip, W., Raviola, G., … Kleinman, A. (2019). A partnership for transforming mental health globally. The Lancet. Psychiatry, 6(4), 350356. doi: 10.1016/s2215-0366(18)30434-6.CrossRefGoogle ScholarPubMed
Vigo, D., Thornicroft, G., & Atun, R. (2016). Estimating the true global burden of mental illness. The Lancet. Psychiatry, 3(2), 171178. doi: 10.1016/s2215-0366(15)00505-2.CrossRefGoogle ScholarPubMed
Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Borges, G., Bromet, E. J., … Wells, J. E. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO World Mental Health Surveys. Lancet (London, England), 370(9590), 841850. doi: 10.1016/s0140-6736(07)61414-7.CrossRefGoogle ScholarPubMed
Wolter, K. (1985). Introduction to variance estimation. New York, NY: Springer- Verlag.Google Scholar
World Health Organization (WHO). (2016). mhGAP Intervention Guide, version 2.0. Geneva, Switzerland. Retrieved from Scholar
Supplementary material: File

Vigo et al. supplementary material

Appendix Tables 1-3

Download Vigo et al. supplementary material(File)
File 36 KB