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

Daniel Vigo, Josep Maria Haro, Irving Hwang, Sergio Aguilar-Gaxiola, Jordi Alonso, Guilherme Borges, Ronny Bruffaerts, Jose Miguel Caldas-de-Almeida, Giovanni de Girolamo, Silvia Florescu, Oye Gureje, Elie Karam, Georges Karam, Viviane Kovess-Masfety, Sing Lee, Fernando Navarro-Mateu, Akin Ojagbemi, Jose Posada-Villa, Nancy A Sampson, Kate ScottJuan Carlos Stagnaro, Margreet Ten Have, Maria Carmen Viana, Chi-Shin Wu, Somnath Chatterji, Pim Cuijpers, Graham Thornicroft, Ronald C Kessler

Research output: Contribution to journalArticlepeer-review


BACKGROUND: 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.

METHODS: 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.

RESULTS: 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.

CONCLUSIONS: 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 languageEnglish
Pages (from-to)1-11
Number of pages11
JournalPsychological Medicine
Publication statusPublished - 20 Oct 2020


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