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Drop out from out-patient mental healthcare in the World Health Organization's World Menta Health Survey initiative

  • J. Elisabeth Wells (a1), Mark Oakley Browne (a2), Sergio Aguilar-Gaxiola (a3), Ali Al-Hamzawi (a4), Jordi Alonso (a5), Matthias C. Angermeyer (a6), Colleen Bouzan (a7), Ronny Bruffaerts (a8), Brendan Bunting (a9), José Miguel Caldas-de-Almeida (a10), Giovanni De Girolamo (a11), Ron De Graaf (a12), Silvia Florescu (a13), Akira Fukao (a14), Oye Gureje (a15), Hristo Ruskov Hinkov (a16), Chiyi Hu (a17), Irving Hwang (a7), Elie G. Karam (a18), Stanislav Kostyuchenko (a19), Viviane Kovess-Masfety (a20), Daphna Levinson (a21), Zhaorui Liu (a22), Maria Elena Medina-Mora (a23), S. Haque Nizamie (a24), José Posada-Villa (a25), Nancy A. Sampson (a7), Dan J. Stein (a26), Maria Carmen Viana (a27) and Ronald C. Kessler (a7)...

Abstract

Background

Previous community surveys of the drop out from mental health treatment have been carried out only in the USA and Canada.

Aims

To explore mental health treatment drop out in the World Health Organization World Mental Health Surveys.

Method

Representative face-to-face household surveys were conducted among adults in 24 countries. People who reported mental health treatment in the 12 months before interview (n = 8482) were asked about drop out, defined as stopping treatment before the provider wanted.

Results

Overall, drop out was 31.7%: 26.3% in high-income countries, 45.1% in upper-middle-income countries, and 37.6% in low/ lower/middle-income countries. Drop out from psychiatrists was 21.3% overall and similar across country income groups (high 20.3%, upper-middle 23.6%, low/lower-middle 23.8%) but the pattern of drop out across other sectors differed by country income group. Drop out was more likely early in treatment, particularly after the second visit.

Conclusions

Drop out needs to be reduced to ensure effective treatment.

Copyright

Corresponding author

J. Elisabeth Wells, Department of Public Health and General Practice, university of Otago, Christchurch PO Box 4345, Christchurch 8140, New Zealand. Email: elisabeth.wells@otago.ac.nz

Footnotes

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Declaration of interest

R.C.K. has been a consultant for AstraZeneca, Analysis Group, Bristol-Myers Squibb, Cerner-Galt Associates, Eli Lilly & Company, GlaxoSmithKline, HealthCore, Health Dialog, Integrated Benefits Institute, John Snow, Kaiser Permanente, Matria, Mensante, Merck & Co., Ortho-McNeil Janssen Scientific Affairs, Pfizer, Primary Care Network, Research Triangle Institute, Sanofi-Aventis Groupe, Shire US, SRA International, Takeda Global Research & Development, Transcept Pharmaceuticals, and Wyeth-Ayerst; has served on advisory boards for Appliance Computing II, Eli Lilly & Company, Mindsite, Ortho-McNeil Janssen Scientific Affairs, Plus One Health Management and Wyeth-Ayerst; and has had research support for his epidemiological studies from Analysis Group, Bristol-Myers Squibb, Eli Lilly & Company, EPI-Q, GlaxoSmithKline, Johnson & Johnson Pharmaceuticals, Ortho-McNeil Janssen Scientific Affairs, Pfizer, Sanofi-Aventis Groupe and Shire US. D.J.S. has received research grants and/or consultancy honoraria from Abbott, AstraZeneca, Eli-Lilly, GlaxoSmithKline, Jazz Pharmaceuticals, Johnson & Johnson, Lundbeck, Orion, Pfizer, Pharmacia, Roche, Servier, Solvay, Sumitomo, Takeda, Tikvah and Wyeth.

Footnotes

References

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Drop out from out-patient mental healthcare in the World Health Organization's World Menta Health Survey initiative

  • J. Elisabeth Wells (a1), Mark Oakley Browne (a2), Sergio Aguilar-Gaxiola (a3), Ali Al-Hamzawi (a4), Jordi Alonso (a5), Matthias C. Angermeyer (a6), Colleen Bouzan (a7), Ronny Bruffaerts (a8), Brendan Bunting (a9), José Miguel Caldas-de-Almeida (a10), Giovanni De Girolamo (a11), Ron De Graaf (a12), Silvia Florescu (a13), Akira Fukao (a14), Oye Gureje (a15), Hristo Ruskov Hinkov (a16), Chiyi Hu (a17), Irving Hwang (a7), Elie G. Karam (a18), Stanislav Kostyuchenko (a19), Viviane Kovess-Masfety (a20), Daphna Levinson (a21), Zhaorui Liu (a22), Maria Elena Medina-Mora (a23), S. Haque Nizamie (a24), José Posada-Villa (a25), Nancy A. Sampson (a7), Dan J. Stein (a26), Maria Carmen Viana (a27) and Ronald C. Kessler (a7)...
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Author's reply

Jessie E. Wells, Research Professor
14 March 2013

We thank Basu et al. for their kind words about our paper and for their reaffirmation of the importance of addressing adherence to treatment.However, while they note that, 'In countries having lesser mental healthcare resources such co-ordinated provision of treatment is lacking,' our results (Table DS2) show that co-ordinated treatment is typically lacking even in higher-income countries. Indeed, the median number of visits in the past twelve months among patients receiving treatment for mental disorders in General Medical Services is no differentin High Income (1.5) than in Low/Lower-Middle Income (1.4) countries and only slightly higher in Upper-Middle Income countries (2.1). We also foundthat the proportion of patients prematurely terminating primary care treatment of mental disorders is quite high in High Income countries (35.4%) as well as in lower income countries (52.5% for both groups).

Although Basu et al. consider the WMH question on stopping treatment irrelevant to relationships with spiritual or religious healers, great care was taken in crafting the question sequence in which this question was embedded to be broadly applicable across treatment sectors and countries. The sequence began by asking respondents if they ever in their life saw any of the professionals on a long country-specific customized list, for problems with their emotions, nerves, or use of alcohol or drugs. Respondents who reported having done so were asked if they saw eachtype of professional for such problems in the past twelve months and, if so, number of visits, perceived helpfulness, and whether or not they were still seeing the professional for these problems. Only those who said theyhad stopped seeing the professional were then asked, 'Did you complete thefull recommended course of treatment? Or did you quit before the wanted you to stop?' We agree with Basu et al. that the framing of this question and of the response options may not have been themost natural way to describe an on-going relationship with a spiritual or religious healer and we agree that customization might well yield important new information. However, we would expect reports of having "stopped" to be lower bound estimates of the extent to which care for on-going emotional problems lacked continuity, so the high proportions of patients in lower income countries who gave such reports are cause for deep concern. Basu et al. also note correctly that data on reasons for terminating treatment, including stigma, were not reported in the paper. Such data exist in the WMH surveys and will be presented in future reports.

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Conflict of interest: None declared

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Drop out from out-patient mental healthcare in the World Health Organization's World Mental Health Survey initiative:

Aniruddha Basu, Psychiatrist
25 February 2013

We read with interest the study titled 'Drop out from out-patient mental healthcare in the World Health Organization's World Mental Health Survey initiative' by J.E. Wells et al.(1) where the important issue of adherence to treatment services has been addressed. Though the study analysed the data generated from the robust methodology of the WMH survey, which is a landmark in the field of psychiatric epidemiology, it needs to address some of the conceptual issues of treatment adherence particularly relevant to the low/lower-middle income countries.

Long term follow-up and regular treatment is mostly prevalent in highincome countries having an organised mental healthcare service. In countries having lesser mental healthcare resources such co-ordinated provision of treatment is lacking. When treatment is sought from general medical services, the patient is only provided symptomatic relief and neither the provider nor the client has any knowledge about long term follow-up. Such lack of communication between them is mostly due to deficiency of mental health infrastructure in terms of either quality or quantity(2). One may argue that traditional or non-conventional modes are main treatment providers in such countries. But for them often the treatment proceeds in an 'as and when required' basis(3). For spiritual and religious healers the client would often be attached to them in a special bond of faith or gratitude for generations like the 'guru chela relationship' paradigm(4) . In such situations, a question like this - 'Did you complete the full recommended course of treatment? Or did you stop before the [provider] wanted you to stop?'- seems irrelevant. So, we propose that a little extra effort to standardise this question in the different settings would have made the methodology more robust.

Slightly different definitions for mental health treatment dropout were used in previous studies(5)(6). The authors have very rightly pointedout that this is one of the reasons for differences between drop-out ratesfound in these national surveys and corresponding sub-samples of the present study. So if such 'slightly different definition' of drop-outs influence their rates in high income countries where the determinants are less heterogeneous, then we can obviously assume that its effect on the low/lower middle income countries will be marked.

Though the authors have made elaborate attempts to find the predictors of drop-out yet they did not take into account many potentially relevant factors related to patient (e.g., stigma, functional impairment, and satisfaction with treatment), professional (e.g., communication skills and clinical expertise), and service (e.g., environmental obstacles the attitudinal factors) delivery. Apart from this, the fact that the centres in some countries were not representative of the whole population influenced generalizability of the study. Overall,this unique effort by the authors is praise-worthy and will go a long way in under-standing the dynamics of treatment drop-outs from a global perspective. References:1. Wells JE, Browne MO, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Angermeyer MC, et al. Drop out from out-patient mental healthcare in the World Health Organization's World Mental Health Survey initiative. Br J Psychiatry. 2013 Jan;202(1):42-9. 2. Organization WH. Mental Health Atlas 2011. World Health Organization; 2011. 3. Chavan BS, Gupta N, Sidana A, Arun P, Jadhav S. Community Mental Health in India. Jp Medical Pub; 2012. 4. Neki JS. Guru-chela relationship: the possibility of a therapeutic paradigm. Am J Orthopsychiatry. 1973 Oct;43(5):755-66. 5. Edlund MJ, Wang PS, Berglund PA, Katz SJ, Lin E, Kessler RC. Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario. Am J Psychiatry. 2002 May;159(5):845-51. 6. Wang J. Mental health treatment dropout and its correlates in a general population sample. Med Care. 2007 Mar;45(3):224-9.

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Conflict of interest: None declared

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