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Patterns of care and dropout rates from outpatient mental healthcare in low-, middle- and high-income countries from the World Health Organization's World Mental Health Survey Initiative

Published online by Cambridge University Press:  28 April 2020

Daniel Fernández
Parc Sanitari Sant Joan de Déu, CIBERSAM, Sant Boi de Llobregat, Barcelona, Spain Serra Húnter fellow. Department of Statistics and Operations Research, Polytechnic University of Catalonia-BarcelonaTech, Barcelona, Spain
Daniel Vigo
Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
Nancy A. Sampson
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
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
Ali O. Al-Hamzawi
College of Medicine, Al-Qadisiya University, Diwaniya Governorate, Iraq
Jordi Alonso
Health Services Research Unit, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain CIBER en Epidemiología y Salud Pública (CIBERESP), Spain Pompeu Fabra University (UPF), Barcelona, Spain
Laura Helena Andrade
Núcleo de Epidemiologia Psiquiátrica – LIM 23, Instituto de Psiquiatria Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
Evelyn J. Bromet
Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York, USA
Giovanni de Girolamo
IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
Peter de Jonge
Department of Developmental Psychology, Rijksuniversiteit Groningen, Groningen, Netherlands Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, Netherlands
Silvia Florescu
National School of Public Health, Management and Development, Bucharest, Romania
Oye Gureje
Department of Psychiatry, University College Hospital, Ibadan, Nigeria
Hristo Hinkov
National Center of Public Health and Analyses, Sofia, Bulgaria
Chiyi Hu
Shenzhen Institute of Mental Health & Shenzhen Kangning Hospital, Shenzhen, China
Elie G. Karam
Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Balamand University, Beirut, Lebanon Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon
Georges Karam
Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Balamand University, Beirut, Lebanon Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon
Norito Kawakami
Department of Mental Health, School of Public Health, The University of Tokyo, Tokyo, Japan
Andrzej Kiejna
Wroclaw Medical University; University of Lower Silesia, Wroclaw, Poland
Viviane Kovess-Masfety
Ecole des Hautes Etudes en Santé Publique (EHESP), EA 4057, Paris Descartes University, Paris, France
Maria E. Medina-Mora
National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico
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 College Hospital, Ibadan, Nigeria
Siobhan O'Neill
School of Psychology, Ulster University, Londonderry, United Kingdom
Marina Piazza
Universidad Cayetano Heredia, Lima, Peru
Jose Posada-Villa
Faculty of Social Sciences, Colegio Mayor de Cundinamarca University, Bogota, Colombia
Charlene Rapsey
Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
David R. Williams
Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
Miguel Xavier
NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal and
Yuval Ziv
Mental Health Services, Israeli Ministry of Health, Jerusalem, Israel
Ronald C. Kessler*
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
Josep M. Haro
Parc Sanitari Sant Joan de Déu, CIBERSAM, Sant Boi de Llobregat, Barcelona, Spain
Author for correspondence: Ronald C. Kessler, E-mail:



There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.


Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan–Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.


Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.


Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.

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

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Agarwal, P., Pan, X., & Sambamoorthi, U. (2013). Depression treatment patterns among individuals with osteoarthritis: A cross sectional study. BMC Psychiatry, 13, 121. doi: 10.1186/1471-244X-13-121.CrossRefGoogle ScholarPubMed
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 Psychiatric Association (APA) (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Arlington: American Psychiatric Publishing, Inc.Google Scholar
American Psychiatric Association (APA) (2010). Practice guidelines for the treatment of patients with major depressive disorder. Washington, DC: American Psychiatric Association (APA). ( Accessed 28 September 2019.Google Scholar
Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 110. doi: 10.2307/2137284.CrossRefGoogle ScholarPubMed
Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A., Borges, G., … Kessler, R. C. (2014). Barriers to mental health treatment: Results from the WHO World Mental Health surveys. Psychological Medicine, 44(6), 13031317. doi: 10.1017/S0033291713001943.CrossRefGoogle ScholarPubMed
Barnicot, K., Katsakou, C., Marougka, S., & Priebe, S. (2011). Treatment completion in psychotherapy for borderline personality disorder – a systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 123(5), 327338. doi: 10.1111/j.1600-0447.2010.01652.x.CrossRefGoogle ScholarPubMed
Belleau, E. L., Chin, E. G., Wanklyn, S. G., Zambrano-Vazquez, L., Schumacher, J. A., & Coffey, S. F. (2017). Pre-treatment predictors of dropout from prolonged exposure therapy in patients with chronic posttraumatic stress disorder and comorbid substance use disorders. Behaviour Research and Therapy, 91, 4350. doi: 10.1016/j.brat.2017.01.011.CrossRefGoogle ScholarPubMed
Centorrino, F., Hernán, M. A., Drago-Ferrante, G., Rendall, M., Apicella, A., Längar, G., & Baldessarini, R. J. (2002). Factors associated with noncompliance with psychiatric outpatient visits. Psychiatric Services, 52(3), 378380. doi: 10.1176/ Scholar
Cooper, A. A., & Conklin, L. R. (2015). Dropout from individual psychotherapy for major depression: A meta-analysis of randomized clinical trials. Clinical Psychology Review, 40, 5765. doi: 10.1016/j.cpr.2015.05.001.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. Journal of the American Medical Association, 291(21), 25812590. doi: 10.1001/jama.291.21.2581.Google ScholarPubMed
Edlund, M. J., Wang, P. S., Berglund, P. A., Katz, S. J., Lin, E., & Kessler, R. C. (2002). Dropping out of mental health treatment: Patterns and predictors among epidemiological survey respondents in the United States and Ontario. American Journal of Psychiatry, 159(5), 845851. doi: 10.1176/appi.ajp.159.5.845.CrossRefGoogle ScholarPubMed
Evans-Lacko, S., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Benjet, C., Bruffaerts, R., … Thornicroft, G. (2018). Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: Results from the WHO World Mental Health (WMH) surveys. Psychological Medicine, 48(9), 15601571. doi: 10.1017/S0033291717003336.CrossRefGoogle ScholarPubMed
Fassino, S., Pierò, A., Tomba, E., & Abbate-Daga, G. (2009). Factors associated with dropout from treatment for eating disorders: A comprehensive literature review. BMC Psychiatry, 9, 67. doi: 10.1186/1471-244X-9-67.CrossRefGoogle ScholarPubMed
Fernandez-Arias, I., Garcia-Fernandez, G., Bernaldo-de-Quiros, M., Estupinia Puig, F. J., Labrador Encinas, F. J., & Labrador-Mendez, M. (2016). Premature termination of psychological treatment for anxiety disorders in a clinical setting. Psicothema, 28(3), 241246. doi: 10.7334/psicothema2015.201.Google ScholarPubMed
Fletcher, J., Bower, P. J., Gilbody, S., Lovell, K., Richards, D., & Gask, L. (2009). Collaborative care for depression and anxiety problems in primary care. Cochrane Database of Systematic Reviews, (2), 1256. doi: 10.1002/14651858.CD006525.Google Scholar
Gautam, S., Jain, A., Gautam, M., Vahia, V., & Grover, S. (2017). Clinical practice guidelines for the management of depression. Indian Journal of Psychiatry, 59(Suppl 1), S34S50. doi: 10.4103/0019-5545.196973.Google ScholarPubMed
Gonzalez, A., Weersing, V. R., Warnick, E. M., Scahill, L. D., & Woolston, J. L. (2011). Predictors of treatment attrition among an outpatient clinic sample of youths with clinically significant anxiety. Administration and Policy in Mental Health and Mental Health Services Research, 38(5), 356367. doi: 10.1007/s10488-010-0323-y.CrossRefGoogle ScholarPubMed
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. G., Wells, J. E., Hubbard, F., Mneimneh, Z., Chiu, W. T., Sampson, N. A., & Berglund, P. A. (2008). Sample designs and sampling procedures. In Kessler, R. C. and Üstun, T. B. (Eds), The WHO World Mental Health Surveys: Global perspectives on the epidemiology of mental Disorders (pp. 1832). Cambridge: Cambridge University Press.Google Scholar
Hoyer, J., Wiltink, J., Hiller, W., Miller, R., Salzer, S., Sarnowsky, S., … Leibing, E. (2016). Baseline patient characteristics predicting outcome and attrition in cognitive therapy for social phobia: Results from a large multicentre trial. Clinical Psychology and Psychotherapy, 23(1), 3546. doi: 10.1002/cpp.1936.CrossRefGoogle ScholarPubMed
Huas, C., Godart, N., Foulon, C., Pham-Scottez, A., Divac, S., Fedorowicz, V., … Rouillon, F. (2011). Predictors of dropout from inpatient treatment for anorexia nervosa: Data from a large French sample. Psychiatry Research, 185(3), 421426. doi: 10.1016/j.psychres.2009.12.004.CrossRefGoogle Scholar
Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., … Walters, E. E. (2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, 35(2), 245256. doi: 10.1017/s0033291704002892.CrossRefGoogle Scholar
Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., … Wang, P. S. (2009). The global burden of mental disorders: An update from the WHO World Mental Health (WMH) surveys. Epidemiologia e Psichiatria Sociale, 18(1), 2333. doi: 10.1017/s1121189x00001421.CrossRefGoogle ScholarPubMed
Kessler, R. C., & Üstün, 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(1), 93121. doi: 10.1002/mpr.168.CrossRefGoogle Scholar
Murphy, D., Hodgman, G., Carson, C., Spencer-Harper, L., Hinton, M., Wessely, S., & Busuttil, W. (2015). Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD): A naturalistic study to explore dropout and health outcomes at follow-up. BMJ Open, 5, 19. doi: 10.1136/bmjopen-2014-007051.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence (NICE) (2004). Depression: The treatment and management of depression in adults. NICE guidelines [CG23]. London, UK: NICE ( Accessed 28 September 2019.Google Scholar
National Institute for Health and Care Excellence (NICE) (2009). Depression: The treatment and management of depression in adults. NICE guidelines [CG90]. London, UK: NICE ( Accessed 28 September 2019.Google Scholar
Oflaz, S., Guveli, H., Kalelioglu, T., Akyazi, S., Yildizhan, E., Kilic, K. C., … Oral, E. T. (2015). Illness perception of dropout patients followed up at bipolar outpatient clinic, Turkey. Asian Journal of Psychiatry, 15, 6872. doi: 10.1016/j.ajp.2015.04.006.CrossRefGoogle ScholarPubMed
Olfson, M., Mojtabai, R., Sampson, N. A., Hwang, I., Druss, B., Wang, P. S., … Kessler, R. C. (2009). Dropout from outpatient mental health care in the United States. Psychiatric Services, 60(7), 898907. doi: 10.1176/ ScholarPubMed
Pan, Y. J., Liu, S. K., & Yeh, L. L. (2013). Factors affecting early attrition and later treatment course of antidepressant treatment of depression in naturalistic settings: An 18-month nationwide population-based study. Journal of Psychiatric Research, 47(7), 916925. doi: 10.1016/j.jpsychires.2013.03.005.CrossRefGoogle ScholarPubMed
Pennell, B. E., Mneimneh, Z., Bowers, A., Chardoul, S., Wells, J. E., Viana, M. C., … Villagut Saiz, G. (2008). Implementation of the World Mental Health Surveys. In Kessler, R. C. and Üstun, T. B. (Eds), The WHO World Mental Health Surveys: Global perspectives on the epidemiology of mental disorders. (pp. 3557). Cambridge: Cambridge University Press.Google Scholar
Petterson, S., Miller, B. F., Payne-Murphy, J. C., & Phillips, R. L. (2014). Mental health treatment in the primary care setting: Patterns and pathways. Families Systems and Health, 32(2), 157166. doi: 10.1037/fsh0000036.CrossRefGoogle ScholarPubMed
Research Triangle Institute. (2002). SUDAAN 8.0. Research Triangle Park, NC: Research Triangle Institute.Google Scholar
Roberts, A., Murphy, R., Turner, J., & Sharman, S. (2020). Predictors of dropout in disordered gamblers in UK residential treatment. Journal of Gambling Studies, 36(1), 373386. doi: 10.1007/s10899-019-09876-7.CrossRefGoogle ScholarPubMed
Roos, J., & Werbart, A. (2013). Therapist and relationship factors influencing dropout from individual psychotherapy: A literature review. Psychotherapy Research, 23(4), 394418. doi: 10.1080/10503307.2013.775528.CrossRefGoogle ScholarPubMed
SAS Institute (2002). SAS 9.4. Cary, NC: SAS Institute Inc.Google Scholar
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
Simon, G. E., & Ludman, E. J. (2010). Predictors of early dropout from psychotherapy for depression in community practice. Psychiatric Services, 61(7), 684689. doi: 10.1176/ps.2010.61.7.684.CrossRefGoogle ScholarPubMed
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547559. doi: doi:10.1037/a0028226.CrossRefGoogle ScholarPubMed
Wang, J. L. (2007). Mental health treatment dropout and its correlates in a general population sample. Medical Care, 45(3), 224229. doi: 10.1097/01.mlr.0000244506.86885.a5.CrossRefGoogle Scholar
Warden, D., Rush, A. J., Carmody, T. J., Kashner, T. M., Biggs, M. M., Crismon, M. L., & Trivedi, M. H. (2009 b). Predictors of attrition during one year of depression treatment: A roadmap to personalized intervention. Journal of Psychiatric Practice, 15(2), 113124. doi: 10.1097/01.pra.0000348364.88676.83.CrossRefGoogle ScholarPubMed
Warden, D., Rush, A. J., Wisniewski, S. R., Lesser, I. M., Thase, M. E., Balasubramani, G. K., … Trivedi, M. H. (2009 a). Income and attrition in the treatment of depression: A STAR*D report. Depression and Anxiety, 26(7), 622633. doi: 10.1002/da.20541.CrossRefGoogle ScholarPubMed
Wells, J. E., Browne, M. O., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Angermeyer, M. C., … Kessler, R. C. (2013). Drop out from out-patient mental healthcare in the World Health Organization's World Mental Health Survey initiative. British Journal of Psychiatry, 202(1), 4249. doi: 10.1192/bjp.bp.112.113134.CrossRefGoogle ScholarPubMed
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24(2), 190195. doi: 10.1037/0735-7028.24.2.190.CrossRefGoogle Scholar
World Health Organization (WHO). (2017). Project atlas: Resources for mental health. Geneva: World Health Organization ( Accessed 28 September 2019.Google Scholar
Xiang, Y.-T., Weng, Y.-Z., Leung, C.-M., Tang, W.-K., Chan, S. S. M., Wang, C.-Y., … Ungvari, G. S. (2010). Gender differences in sociodemographic and clinical characteristic and the quality of life of Chinese schizophrenia patients. Australian and New Zealand Journal of Psychiatry, 44(5), 450455. doi: 10.3109/00048670903489858.CrossRefGoogle ScholarPubMed
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