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Table 1.  Lifetime Prevalence of DSM-IV Major Depressive Disorder, Proportion of Adults With Lifetime MDD Who Obtained Treatment, and Proportion of Patients Who Perceived Treatment as Helpful
Lifetime Prevalence of DSM-IV Major Depressive Disorder, Proportion of Adults With Lifetime MDD Who Obtained Treatment, and Proportion of Patients Who Perceived Treatment as Helpful
Table 2.  Conditional and Cumulative Probabilities of Depression Treatment Being Perceived as Helpful After Each Professional Seen Among Respondents With Lifetime DSM-IV Major Depressive Disorder Who Obtained Treatment
Conditional and Cumulative Probabilities of Depression Treatment Being Perceived as Helpful After Each Professional Seen Among Respondents With Lifetime DSM-IV Major Depressive Disorder Who Obtained Treatment
Table 3.  Conditional and Cumulative Probability of Persistence With Treatment After Previous Unhelpful Attempts, Among Respondents With Lifetime DSM-IV Major Depressive Disorder Who Obtained Treatment
Conditional and Cumulative Probability of Persistence With Treatment After Previous Unhelpful Attempts, Among Respondents With Lifetime DSM-IV Major Depressive Disorder Who Obtained Treatment
Table 4.  Factors Associated With Helpful Treatment and Persistence (Pooled Across Professionals Seen) and of Perceived Helpfulness of Treatment (Person Level) Among People With Lifetime DSM-IV MDD Who Obtained Treatment
Factors Associated With Helpful Treatment and Persistence (Pooled Across Professionals Seen) and of Perceived Helpfulness of Treatment (Person Level) Among People With Lifetime DSM-IV MDD Who Obtained Treatment
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    Original Investigation
    May 20, 2020

    Findings From World Mental Health Surveys of the Perceived Helpfulness of Treatment for Patients With Major Depressive Disorder

    Author Affiliations
    • 1The University of Queensland School of Public Health, Herston, Queensland, Australia
    • 2Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Queensland, Australia
    • 3Department of Psychology, Yale University, New Haven, Connecticut
    • 4Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    • 5Center for Reducing Health Disparities, UC Davis Health System, Sacramento, California
    • 6Al-Qadisiya University College of Medicine, Diwaniya Governorate, Iraq
    • 7IMIM–Hospital del Mar Research Institute, Parc de Salut Mar, Barcelona, Spain
    • 8Departament de Ciències Experimentals i de la Salut, Pompeu Fabra University, Barcelona, Spain
    • 9CIBER en Epidemiología y Salud Pública, Barcelona, Spain
    • 10Epidemiology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
    • 11Núcleo de Epidemiologia Psiquiátrica (LIM 23), Instituto de Psiquiatria Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
    • 12Lisbon Institute of Global Mental Health and Chronic Diseases Research Center, NOVA Medical School, NOVA University of Lisbon, Lisbon, Portugal
    • 13Anxiety Disorders Center, Buenos Aires, Argentina
    • 14National School of Public Health, Management and Development, Bucharest, Romania
    • 15Department of Psychiatry, University College Hospital, Ibadan, Nigeria
    • 16Shenzhen Institute of Mental Health, Shenzhen Kangning Hospital, Shenzhen, China
    • 17Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University, Beirut, Lebanon
    • 18Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Beirut, Lebanon
    • 19Institute for Development Research Advocacy and Applied Care, Beirut, Lebanon
    • 20Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor
    • 21UDIF-SM, Subdirección General de Planificación, Innovación y Cronicidad, Servicio Murciano de Salud, IMIB-Arrixaca, CIBERESP-Murcia, Murcia, Spain
    • 22Ulster University School of Psychology, Londonderry, United Kingdom
    • 23Department of Psychological Medicine, University of Otago, Dunedin, Otago, New Zealand
    • 24The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
    • 25Center for Excellence on Research in Mental Health, CES University, Medellín, Colombia
    • 26Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
    • 27Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
    • 28National Institute of Public Health–National Institute of Hygiene, Warsaw, Poland
    • 29National Center of Public Health and Analyses, Directorate of Mental Health and Prevention of Addictions, Sofia, Bulgaria
    • 30Mental Health Services, Israeli Ministry of Health, Jerusalem, Israel
    JAMA Psychiatry. Published online May 20, 2020. doi:10.1001/jamapsychiatry.2020.1107
    Key Points

    Question  What proportion of patients with depression perceive treatment as helpful?

    Findings  This study of 80 332 respondents surveyed in 16 countries found that 68.2% of adults with a lifetime history of DSM-IV major depressive disorder (n = 2726) obtained treatment that they considered helpful; other patients stopped seeking treatment after early unhelpful treatment. Most patients (93.9%) were helped if they persisted through 10 treatment professionals, but only 21.5% of patients were that persistent.

    Meaning  Many more patients with major depressive disorder might obtain helpful treatment if they persist after early unhelpful treatment.

    Abstract

    Importance  The perceived helpfulness of treatment is an important patient-centered measure that is a joint function of whether treatment professionals are perceived as helpful and whether patients persist in help-seeking after previous unhelpful treatments.

    Objective  To examine the prevalence and factors associated with the 2 main components of perceived helpfulness of treatment in a representative sample of individuals with a lifetime history of DSM-IV major depressive disorder (MDD).

    Design, Setting, and Participants  This study examined the results of a coordinated series of community epidemiologic surveys of noninstitutionalized adults using the World Health Organization World Mental Health surveys. Seventeen surveys were conducted in 16 countries (8 surveys in high-income countries and 9 in low- and middle-income countries). The dates of data collection ranged from 2002 to 2003 (Lebanon) to 2016 to 2017 (Bulgaria). Participants included those with a lifetime history of treated MDD. Data analyses were conducted from April 2019 to January 2020. Data on socioeconomic characteristics, lifetime comorbid conditions (eg, anxiety and substance use disorders), treatment type, treatment timing, and country income level were collected.

    Main Outcomes and Measures  Conditional probabilities of helpful treatment after seeing between 1 and 5 professionals; persistence in help-seeking after between 1 and 4 unhelpful treatments; and ever obtaining helpful treatment regardless of number of professionals seen.

    Results  Survey response rates ranged from 50.4% (Poland) to 97.2% (Medellín, Columbia), with a pooled response rate of 68.3% (n = 117 616) across surveys. Mean (SE) age at first depression treatment was 34.8 (0.3) years, and 69.4% were female. Of 2726 people with a lifetime history of treatment of MDD, the cumulative probability (SE) of all respondents pooled across countries of helpful treatment after seeing up to 10 professionals was 93.9% (1.2%), but only 21.5% (3.2%) of patients persisted that long (ie, beyond 9 unhelpful treatments), resulting in 68.2% (1.1%) of patients ever receiving treatment that they perceived as helpful. The probability of perceiving treatment as helpful increased in association with 4 factors: older age at initiating treatment (adjusted odds ratio [AOR], 1.02; 95% CI, 1.01-1.03), higher educational level (low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level), shorter delay in initiating treatment after first onset (AOR, 0.98; 95% CI, 0.97-0.99), and medication received from a mental health specialist (AOR, 2.91; 95% CI, 2.04-4.15). Decomposition analysis showed that the first 2 of these 4 factors were associated with only the conditional probability of an individual treatment professional being perceived as helpful (age at first depression treatment: AOR, 1.02; 95% CI, 1.01-1.02; educational level: low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high-average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level), whereas the latter 2 factors were associated with only persistence (treatment delay: AOR, 0.98; 95% CI, 0.97-0.99; treatment type: AOR, 3.43; 95% CI, 2.51-4.70).

    Conclusions and Relevance  The probability that patients with MDD obtain treatment that they consider helpful might increase, perhaps markedly, if they persisted in help-seeking after unhelpful treatments with up to 9 prior professionals.

    Major depressive disorder (MDD) is associated with the number of years lived with disability globally,1 affecting approximately 5% to 6% of people worldwide each year and 11% to 15% of people for a lifetime.2,3 The high burden of MDD exists, in part, because many people do not receive effective care.4,5 Many studies have defined potentially effective care for MDD using objective criteria, usually in terms of the number of professional visits and either the type of professional seen or the type of intervention received. However, patient-centered definitions can also help to identify needs that are not fully met by treatment and in turn can inform policy and service responses to address these needs.6-8 Thus, a patient’s evaluation of the helpfulness of treatment is an important measure9,10 that can be collected directly and efficiently11,12 and, when assessed in population surveys, can help fill a knowledge gap about treatment outcomes at a population level.11

    In epidemiologic studies, approximately 55% to 75% of adults seeking help for depression or other mental health needs say they received treatment or professional contact that was at least somewhat helpful.12-17 With some exceptions,16,17 available studies of the helpfulness of depression treatment have focused on treatment received during a short term among prevalent cases rather than taking a longer-term perspective. This focus provides only a partial understanding because it excludes the many incident MDD cases in which patients take longer than 12 months to initiate treatment17-20 and captures only a subset of the long-term course of MDD21 across the complete treatment pathway.22

    A patient’s pathway through care may involve contact with numerous professionals, each of whom may or may not provide treatment that the patient considers helpful, and this experience may consequently encourage or discourage future attempts by the patient to seek care either in the current episode or in subsequent episodes.23,24 An evaluation of this pathway through care requires information about the sequence of contacts with health professionals following the onset of the disorder. Given this information, the probability of a patient ever receiving helpful depression treatment will mathematically be the product of 2 components: the probability of a given treatment professional being perceived as helpful and the probability that the patient will persist in help-seeking after receiving unhelpful treatment.25 Decomposing the treatment pathway in this way is potentially informative because these 2 components could have different determinants. Moreover, they may vary across mental health service contexts, being associated with factors such as availability of services and barriers to access. Here, we examined the prevalence and factors associated with perceived helpfulness of treatment and of its 2 main components based on retrospective reports obtained in a cross-national, representative community sample of individuals with a lifetime history of depression treatment.

    Methods
    Sample

    The World Health Organization (WHO) World Mental Health (WMH) surveys are a coordinated set of community epidemiologic surveys administered to probability samples of the noninstitutionalized household population in countries throughout the world.26,27 Data for the present report were collected from 17 WMH surveys carried out in 16 countries—8 surveys in countries classified by the World Bank as high-income countries (Argentina; Australia; Israel; Murcia, Spain; Northern Ireland; Poland; Portugal; and Saudi Arabia) and 9 surveys in countries classified as low- and middle-income countries (São Paulo, Brazil; Bulgaria; Medellín, Colombia; Iraq; Lebanon; Nigeria; Shenzhen, People’s Republic of China; and Romania). There were 2 surveys in Bulgaria administered to separate samples from 2002 to 2006 and from 2016 to 2017. Eleven surveys were based on nationally representative household samples, whereas 3 surveys were representative of selected metropolitan areas (São Paulo, Brazil; Medellín, Colombia; and Shenzhen, People’s Republic of China), 2 surveys of selected regions (Murcia, Spain, and selected states in Nigeria), and 1 survey of all urbanized areas (Argentina). The field dates ranged from 2002 to 2003 (Lebanon) to 2016 to 2017 (Bulgaria). Response rates ranged from 50.4% (Poland) to 97.2% (Medellín, Columbia), with a pooled response rate of 68.3% (n = 117 616) across surveys (eTable 1 in the Supplement). The study protocol was approved by all local institutional review boards. Written or verbal informed consent was obtained in a manner consistent with the regulations of each country. Small compensation or gifts were offered as incentives for participating in this study as approved by local institutional review boards.28

    The interview schedule was developed in English and translated into other languages using a standardized WHO translation, team translation, and harmonization protocol.29 Interviews were administered face to face in respondents’ homes after obtaining informed consent. Interviews were conducted in 2 parts. Part 1 was administered to all 80 332 respondents across all surveys, and core DSM-IV mental disorders were assessed. Part 2 assessed additional disorders and correlates and was administered to 46 500 respondents who met lifetime criteria for any part 1 disorder and to a probability subsample of other part 1 respondents.

    Measures
    Major Depressive Disorder

    Diagnoses were based on version 3.0 of the WHO Composite International Diagnostic Interview (CIDI),26 a fully structured lay-administered diagnostic interview. The DSM-IV criteria were used to define a major depressive episode, mania, and hypomania. The requirement that symptoms do not meet criteria for a mixed episode (criterion C for mania or hypomania and criterion B for major depressive episode) was not used in making these diagnoses. We also defined subthreshold bipolar disorder as a history of recurrent subthreshold hypomania (at least 2 criterion B symptoms along with all other criteria for hypomania). The reduction in the number of required symptoms for a determination of subthreshold hypomania was confined to 2 criterion B symptoms (from the DSM-IV requirement of 3 or 4 if mood is only irritable) to retain the core features of hypomania in the subthreshold definition. Bipolar spectrum disorder was defined as having a history of mania, hypomania, or subthreshold hypomania. Lifetime MDD was then defined conservatively as having a history of major depressive episodes in the absence of a history of bipolar spectrum disorder.30 All diagnoses excluded cases with plausible organic causes. Clinical reappraisal interviews were carried out in several countries in conjunction with WMH surveys using the lifetime nonpatient version of the Structured Clinical Interview for DSM-IV (SCID)31 as the criterion standard. Good agreement was found between diagnoses of MDD based on the CIDI and those based on blinded Structured Clinical Interview clinician-administered reappraisal interviews (κ = 0.54; positive predictive value, 0.74).32

    Perceived Helpfulness of Treatment of Depression

    Respondents who met lifetime DSM-IV and CIDI criteria for MDD were asked retrospectively about age at onset and were then asked “Did you ever in your life talk to a medical doctor or other professional about your (sadness/or/discouragement/or/lack of interest)?” (exact wording based on responses to earlier questions; emphasis in original); if so, respondents were asked “How old were you the first time you talked to a professional about your (sadness/or/discouragement/or/lack of interest)?” “Other professionals” were defined broadly to include psychologists, counselors, spiritual advisors, herbalists, acupuncturists, and other healing professionals. Respondents who said that they had talked to a professional were then asked “Did you ever get treatment for your (sadness/or/discouragement/or/lack of interest) that you considered helpful or effective?” If they said yes, they were asked “How many professionals did you ever talk to about your (sadness/or/discouragement/or/lack of interest) up to and including the first time you ever got helpful treatment?” If they said no, they were asked “How many professionals did you ever talk to about your (sadness/or/discouragement/or/lack of interest)?”

    Factors Associated With Perceived Helpfulness

    Socioeconomic characteristics included age at first depression treatment (continuous), sex, marital status (married, never married, or previously married) at the time of first MDD treatment, and educational level (in quartiles defined by within-country distributions) at the time of first treatment. Lifetime comorbid conditions included number of anxiety disorders and substance use disorders with first onsets prior to the age at first treatment, which are thought to be associated with an increased mental health burden among individuals with MDD.33-36 Anxiety disorders included generalized anxiety disorder, panic disorder, agoraphobia with or without panic disorder, posttraumatic stress disorder, specific phobia, and social phobia. Substance use disorders included alcohol and illicit drug abuse and dependence. Treatment type was defined as the cross-classification of factors for (1) whether the respondent reported receiving medication, talk therapy, or both as of the age at first depression treatment and (2) types of treatment professionals seen as of that age, including mental health specialists (psychiatrist, psychiatric nurse, psychologist, psychiatric social worker, and mental health counselor), primary care physician, human services professionals (social worker or counselor in a social services agency or a spiritual advisor), and complementary or alternative medicine professionals (other type of healer or self-help group). Treatment timing included a dichotomous measure for whether the respondent’s first attempt to seek treatment occurred before 2000 or subsequently (2000 being the typical midpoint time between the start of observation and the survey field dates) and a continuous variable for length of delay in years between age at onset of MDD and age at time of initially seeking treatment.

    Statistical Analysis

    The analysis sample was limited to people with onset of lifetime DSM-IV MDD treatment during or after 1990 to focus on treatments subsequent to the widespread introduction of selective serotonin reuptake inhibitors.37 To investigate the 2 components of helpful treatment separately, we used discrete-event survival analysis to calculate the conditional and cumulative probabilities of (1) obtaining helpful treatment after seeing between 1 and 10 professionals and (2) persisting in seeking treatment with between 2 and 10 professionals after obtaining prior unhelpful treatment.38 We followed up with patients through 10 professionals because this was the highest number of professionals that our required minimum of at least 30 patients had received treatment from (see eTable 2 and eTable 3 in the Supplement for the full set of conditional and cumulative probabilities of receiving helpful treatment and persistence beyond 10 professionals). We then carried out parallel survival analyses of the factors associated with these 2 component outcomes using standard discrete-time methods and a logistic link function,39 followed by a person-level model of overall probability of ever receiving helpful treatment regardless of the number of professionals seen.

    Individual weights were applied to adjust for probability of selection, nonresponse, and poststratification. In addition, data from part 2 respondents were weighted to adjust for differential probabilities of selection into part 2 and deviations between the sample and population demographic-geographic distributions. This weight resulted in prevalence estimates of part 1 disorders in the weighted part 2 sample being virtually identical to those in the part 1 sample.40 Because the WMH sample designs used weighting and clustering, all statistical analyses were carried out using the Taylor series linearization method,41 a design-based method implemented in SAS, version 9.4.42 Logistic regression coefficients and ±2 of their design-based standard errors (SEs) were exponentiated to create odds ratios (ORs) and 95% CIs. The significance of the sets of coefficients was evaluated with Wald χ2 tests based on design-corrected coefficient variance-covariance matrices. Statistical significance was evaluated consistently from April 2019 to January 2020 using 2-sided design-based .05 probability level tests.

    Results
    Perceived Helpfulness of Treatment

    Across all countries combined, 37.2% (n = 7448) of adults with lifetime DSM-IV MDD reported ever being treated, and of those treated, 68.2% (n = 2726) reported ever obtaining treatment that they considered helpful (Table 1). Mean (SE) age at first depression treatment was 34.8 (0.3) years, and 69.4% were female. The mean (SE) treatment probability among all people with lifetime MDD receiving treatment in high-income countries (47.1% [1.0%]) was approximately twice that of comparable people in low- and middle-income countries (22.5% [1.0%]), but the mean (SE) probabilities of treated patients reporting that treatment was helpful were similar (70.1% [1.2%] vs 62.4% [2.2%], respectively).

    Helpful Depression Treatment by Number of Professionals Seen

    Across all countries combined, 30.6% (SE, 0.9%) of patients said that they were helped by the first professional seen (Table 2). The conditional probability of a second professional being helpful after initial unhelpful treatment was 39.6% (SE, 1.7%). The conditional probabilities of receiving helpful treatment after each subsequent professional seen were in the range of 37.4% (SE, 2.5%) after 3 visits to 5.1% (SE, 2.4%) after 7 visits.

    Survival analysis showed that the cumulative probability of receiving helpful treatment increased from 30.6% (SE, 0.9%) after the first professional seen to 58.1% (SE, 1.3%) when patients persevered in trying a second professional after unhelpful treatment from the first, with 93.9% (SE, 1.2%) projected to receive helpful treatment if they persevered in trying up to 10 professionals after earlier ones were unhelpful (Table 2). Patterns and probabilities were generally similar across country income levels.

    Persistence With Depression Help-Seeking Following Treatment Failure

    Across all countries, at least three-quarters of those who were not helped by an initial professional (range, 74.4%-96.7%) persisted in seeing another professional (Table 3). However, because not all people persisted after each unhelpful attempt, the cumulative probability of persisting through 10 professionals was only 21.5% (SE, 3.2%). Patterns were generally similar across country income levels.

    Factors Associated With Helpful Depression Treatment

    Table 4 gives the results of 3 multivariate models assessing whether treatment was helpful pooled across all professionals seen by each patient (model 1), whether patients persisted in help-seeking after previous unhelpful treatment pooled across subsequent professionals seen after an earlier unhelpful professional (model 2), and whether helpful treatment was obtained at the person level regardless of number of treatment professionals seen (model 3). We focused on how the results from the pooled models helped explain the associations in the person-level model.

    Adjusting for all other variables in the model, we found that the relative odds of treatment being perceived as helpful at the person level were higher among patients who were older (adjusted odds ratio [AOR], 1.02; 95% CI, 1.01-1.03) and highly educated (educational level low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high-average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level) at the time of treatment. Decomposition into the 2 components of helpful treatment showed that these variables were associated with significantly elevated relative odds of treatment from a given professional being helpful (age: AOR, 1.02; 95% CI, 1.01-1.02; higher education level [low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high-average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level]) rather than increased persistence after unhelpful treatment (age: AOR, 1.00; 95% CI, 0.99-1.01; higher education level [low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high-average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level]).

    Shorter delay to first treatment from age at onset was also associated with increased relative odds of treatment being perceived as helpful at the person level (AOR, 0.98; 95% CI, 0.97-0.99). The same was true for obtaining medication and treatment from a mental health specialist (AOR, 2.91; 95% CI, 2.04-4.15). Decomposition showed that these associations were due to increased persistence after unhelpful treatment (treatment delay: AOR, 0.98; 95% CI, 0.97-0.99; treatment type: AOR, 3.43; 95% CI, 2.51-4.70) rather than to these factors showing increased odds of treatment from a given professional being perceived as helpful (treatment delay: AOR, 0.99; 95% CI, 0.99-1.00; treatment type: AOR, 1.01; 95% CI, 0.83-1.22).

    Starting treatment in 2000 or later was associated with significantly elevated odds of treatment from a given professional being helpful and also with significantly decreased odds of persistence following unhelpful treatment. These 2 opposite-sign associations cancelled each other so that there was no significant overall time trend in treatment being perceived as helpful. Treatment provided by human services, general medical, or complementary or alternative medicine professionals was negatively associated with helpful treatment from a given professional but positively associated with persistence, resulting in no significant association at the person level. We also estimated more complex models that included interactions between country income level and each of the other factors, but few interactions were statistically significant (eTable 4 in the Supplement).

    Discussion

    In this analysis of data from WHO World Mental Health surveys across 16 countries combined, 68.2% of adults with a lifetime history of treated DSM-IV MDD reported ever obtaining treatment that they considered helpful. Our key finding was that persistence in help-seeking was associated with greatly increased likelihood that treatment would be perceived as helpful. The vast majority (93.9%) of patients who persisted in help-seeking through 10 professionals after earlier unhelpful treatment eventually received treatment that they considered helpful. However, persistence through 10 professionals was observed for only 21.5% of patients.

    The estimate that approximately two-thirds of people seeking help for MDD eventually obtained treatment that they considered helpful is consistent with previous epidemiologic studies.12-17 Our decomposition analyses extended these previous findings. Compounding the modest rates of perceived helpfulness of treatment from individual professionals, only 21.5% of patients persisted in seeing up to 10 different professionals when earlier ones had been unhelpful. We do not know whether people who did not persist had expectations of treatment similar to those who did persist, nor can we be certain that they would have had similar outcomes if they had all persisted. However, to the extent that they were similar, our findings suggested that many more people with MDD would receive treatment that they would consider helpful if they had persisted after earlier treatment failures.

    Consistent with some previous findings, relatively older and highly educated people were more likely to report receiving helpful treatment.15,43,44 We found that this result was due to the increased likelihoods of these people perceiving treatments as helpful rather than due to greater persistence in help-seeking after earlier unhelpful treatments. The opposite was true, though, for the other 2 factors associated with receiving helpful treatment (ie, short delays in initiating help-seeking after first onset, and receiving medication and treatment from a mental health professional). Both of these factors were associated with increased persistence of help-seeking rather than with increased likelihood of the treatments being perceived as helpful. Because people who receive medication from mental health specialists are likely to be more severely unwell, persisting in help-seeking after earlier failures might equate to persisting with treatment until an adequate “dose” has been received.45 We were unable to examine perceived helpfulness of depression treatment among people with different types of pathways (eg, based on timing or combinations of professionals talked to) because the depression-specific treatment questions did not capture these details.

    The finding that people who initiated treatment as of 2000 or later were more likely to report treatment from individual professionals as helpful is encouraging in suggesting that treatment has improved over time from the patient perspective. Less encouraging, though, was a time trend for reduced persistence in help-seeking after prior unhelpful treatment. It is unclear why this would be the case, but one possibility is an increase in expectations of treatment. This reduced persistence may help explain why the prevalence of major depression has not decreased with time despite treatment increasing.46

    The extent to which perceived helpfulness is associated with actual helpfulness as assessed in objective measures of treatment outcome, such as those used in clinical trials, is difficult to determine because perceived helpfulness and outcome are overlapping domains rather than distinct domains. For example, perceived helpfulness, subjective well-being, feeling better about the present and the future, perceived quality of life, and having a greater purpose in life—all factors of perception—are associated directly with morbidity and mortality.47,48 Thus, the perceptions that patients have at the end of treatment are not trivial. Indeed, such perceptions are taking on increased importance given that improving depression symptoms might not be associated with other aspects of everyday life for which treatment is sought.7,49,50

    Direct tests of perceived helpfulness and treatment outcome have not been reported in a way that would permit drawing firm conclusions. Among the reasons is that many competing factors (eg, severity of patient symptoms and premorbid social competence) that might well be associated with perceived helpfulness are already known to be associated with therapeutic change.51,52 Yet adjacent literature focuses on perceptions of diverse facets of treatment and therapeutic change. For example, patient expectations for improvement, perceptions of the helpfulness of the relationship with the therapist (therapeutic alliance), perceptions of few obstacles or barriers to treatment, and views of the acceptability of the treatment procedures are all positively associated with therapeutic change in the small to moderate range.53-59 These findings might lead to the argument that helpfulness as a perception is valuable in its own right given its associations with improved functioning and symptom change.

    Limitations

    We know of no previous research that has attempted to decompose patterns or factors associated with perceived helpfulness of treatment of MDD in the manner we used in the present study. Even so, important limitations should be acknowledged. First, we had no means of corroborating respondents’ recall of lifetime symptoms and treatment timing. People who did not obtain treatment may have failed to recall their symptoms or recalled them as less problematic,60 potentially underestimating the probability of MDD and overestimating the extent to which MDD treatment is helpful. Telescoping (ie, dating past events as occurring more recently than they did) might also have occurred and led to inaccurate estimates of the timing of symptoms or treatment.61 The WMH surveys attempt to minimize this kind of recall bias by using procedures to aid memory search.26 In the present study, we also restricted the sample to patients initiating MDD treatment during or after 1990. However, these strategies did not guarantee that we removed recall errors that might have distorted results.

    Second, the measures of perceived helpfulness of treatment were based on a single question asking respondents whether and when they “talk(ed) to” a professional about their depression and follow-up questions about whether they ever received “helpful or effective” treatment and about the number of professionals talked to up to the time that helpful or effective treatment was obtained. We have no way of knowing whether these were formal or therapeutic consultations, the type(s) or appropriateness of clinical activities undertaken, or how encounters with a team of professionals were counted. Nor do we know how patients determined whether treatment was helpful.

    Third, it is unknown whether unmeasured factors were associated with both low perceived helpfulness of treatment and low persistence in help-seeking after prior unhelpful treatments. If so, then the suggestion that the proportion of patients obtaining helpful treatment might increase if greater persistence was encouraged could be incorrect or overestimated.

    Despite these limitations, the findings are provocative and may provide clues about how to improve treatment delivery and decrease steps in the pathway that must be traversed before treatment is considered helpful. Such insights could be valuable both in terms of reducing symptom duration prior to receiving helpful treatment and in terms of reducing the economic waste of providing unhelpful treatment. Precision treatment assigning holds great promise in this regard but remains an underdeveloped area of investigation.62,63 However, the current results suggested that a more practical approach in the short term might be to emphasize to patients that MDD treatment is a trial and error enterprise that requires persistence.64,65 Shared decision-making and measurement-based care practices may increase opportunities to detect and address patients’ negative evaluations of treatment helpfulness.66,67 Lower rates of people with MDD receiving helpful treatment in low- and middle-income countries than in high-income countries were due mostly to lower rates of obtaining any depression treatment rather than to lower rates of treatment being perceived as helpful once received or persisting with help-seeking, reinforcing the need for local adaptation and scaling up of effective depression interventions in these settings.68-70 Whether improving the perceived helpfulness of depression treatment would reduce the likelihood of future negative outcomes (eg, suicidality, future MDD episodes, or onset of comorbidities) is an important question that will require controlled studies evaluating long-term outcomes. Longitudinal studies of persistence in help-seeking are needed.

    Conclusions

    Perceived helpfulness of treatment is an important health care measure in its own right from a patient-centered perspective. Findings from the present large, community sample are encouraging in that more than two-thirds of those people seeking help for lifetime MDD eventually received depression treatment that they perceived as helpful. However, our findings also suggested that this percentage might increase markedly if patients persisted in help-seeking after earlier treatment failures. Evidence regarding the extent to which individualized, targeted treatment can reduce the number of steps in the pathway to helpful treatment is needed.

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    Article Information

    Accepted for Publication: January 31, 2020.

    Corresponding Author: Ronald C. Kessler, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (kessler@hcp.med.harvard.edu).

    Published Online: May 20, 2020. doi:10.1001/jamapsychiatry.2020.1107

    Author Contributions: Dr Kessler had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Harris, E. G. Karam, G. Karam, Mneimneh, O’Neill, Vigo, Kessler.

    Acquisition, analysis, or interpretation of data: Harris, Kazdin, Chiu, Sampson, Aguilar-Gaxiola, Al-Hamzawi, Alonso, Altwaijri, Andrade, Cardoso, Cía, Florescu, Gureje, Hu, E. G. Karam, G. Karam, Navarro-Mateu, Oladeji, O’Neill, Scott, Slade, Torres, Vigo, Wojtyniak, Zarkov, Ziv, Kessler.

    Drafting of the manuscript: Harris, Sampson, E. G. Karam, O’Neill, Zarkov, Kessler.

    Critical revision of the manuscript for important intellectual content: Harris, Kazdin, Chiu, Sampson, Aguilar-Gaxiola, Al-Hamzawi, Alonso, Altwaijri, Andrade, Cardoso, Cía, Florescu, Gureje, Hu, E. G. Karam, G. Karam, Mneimneh, Navarro-Mateu, Oladeji, O’Neill, Scott, Slade, Torres, Vigo, Wojtyniak, Ziv, Kessler.

    Statistical analysis: Chiu, Sampson, E. G. Karam, G. Karam.

    Obtained funding: Alonso, Andrade, Gureje, G. Karam, Navarro-Mateu, Torres, Kessler.

    Administrative, technical, or material support: Kazdin, Sampson, Gureje, Hu, E. G. Karam, G. Karam, Mneimneh, Navarro-Mateu, Oladeji, O’Neill, Ziv.

    Supervision: Sampson, Aguilar-Gaxiola, Alonso, Hu, E. G. Karam, G. Karam, Mneimneh, O’Neill, Vigo.

    Conflict of Interest Disclosures: Ms Sampson reported receiving grants from Bristol-Myers Squibb, Eli Lilly and Company, the Fogarty International Center, GlaxoSmithKline, the John D. and Catherine T. MacArthur Foundation, the National Institute of Mental Health, Ortho-McNeil Pharmaceutical LLC, the Pan American Health Organization, Pfizer, and the United States Public Health Service during the conduct of the study. Dr Mneimneh reported receiving personal fees as a co-director of the data collection center that helps support the implementation of surveys generating the data in this work from the University of Michigan during the conduct of the study. Dr Navarro-Mateu reported receiving nonfinancial support from Otsuka outside the submitted work. Dr Kessler reported receiving grants from Sanofi-Aventis; personal fees from Datastat Inc, Johnson & Johnson Wellness and Prevention, Johnson & Johnson Services Inc Lake Nona Life Project, Sage Therapeutics, Shire, and Takeda outside the submitted work. No other disclosures were reported.

    Funding/Support: The World Health Organization (WHO) World Mental Health (WMH) Survey Initiative is supported by the National Institute of Mental Health (R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the United States Public Health Service (R13 MH066849, R01 MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03 TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical Inc, GlaxoSmithKline, and Bristol-Myers Squibb. The Argentina survey—Estudio Argentino de Epidemiología en Salud Mental—was supported by a grant from the Argentinian Ministry of Health (Ministerio de Salud de la Nación) (2002-17270/13-5). The 2007 Australian National Survey of Mental Health and Wellbeing is funded by the Australian Government Department of Health and Ageing. The São Paulo Megacity Mental Health Survey is supported by the State of São Paulo Research Foundation (FAPESP) Thematic Project grant 03/00204-3. The Bulgarian Epidemiological Study of Common Mental Disorders (EPIBUL) is supported by the Ministry of Health and the National Center for Public Health Protection. The EPIBUL 2, conducted in 2016 to 2017, is supported by the Ministry of Health and European Economic Area grants. The Mental Health Study Medellín–Colombia was carried out and supported jointly by the Center for Excellence on Research in Mental Health (CES University) and the Secretary of Health of Medellín. Implementation of the Iraq Mental Health Survey (IMHS) and data entry were carried out by the staff of the Iraqi Ministry of Health and Ministry of Planning with direct support from the Iraqi IMHS team with funding from both Japanese and European Funds through United Nations Development Group Iraq Trust Fund. The Israel National Health Survey is funded by the Ministry of Health with support from the Israel National Institute for Health Policy and Health Services Research and the National Insurance Institute of Israel. The Lebanese Evaluation of the Burden of Ailments and Needs of the Nation is supported by the Lebanese Ministry of Public Health, the WHO (Lebanon), the National Institute of Health/Fogarty International Center (R03 TW006481-01), anonymous private donations to the Institute for Development, Research, Advocacy and Applied Care, Lebanon, and unrestricted grants from Algorithm, AstraZeneca, Benta Pharma Industries, Bella Pharma, Eli Lilly and Company, GlaxoSmithKline, Lundbeck, Novartis, OmniPharma, Pfizer, Phenicia Pharmaceuticals, Servier, and United Planning Organization. The Nigerian Survey of Mental Health and Wellbeing is supported by the WHO (Geneva), the WHO (Nigeria), and the Federal Ministry of Health, Abuja, Nigeria. The Northern Ireland Study of Mental Health was funded by the Health & Social Care Research & Development Division of the Public Health Agency. The Polish project Epidemiology of Mental Health and Access to Care–EZOP Project (PL 0256) was supported by Iceland, Liechtenstein, and Norway through funding from the European Economic Area Financial Mechanism and the Norwegian Financial Mechanism. The EZOP project was cofinanced by the Polish Ministry of Health. The Portuguese Mental Health Study was carried out by the Department of Mental Health, Faculty of Medical Sciences, NOVA University of Lisbon, with collaboration of the Portuguese Catholic University, and was funded by Champalimaud Foundation, Gulbenkian Foundation, Foundation for Science and Technology, and the Ministry of Health. The Romania WMH study projects “Policies in Mental Health Area” and “National Study Regarding Mental Health and Services Use” were carried out by National School of Public Health & Health Services Management (formerly the National Institute for Research & Development in Health), with technical support of Metro Media Transilvania, the National Institute of Statistics-National Centre for Training in Statistics, SC Cheyenne Services SRL, and Statistics Netherlands, and were funded by the Ministry of Public Health (formerly Ministry of Health) with supplemental support from Eli Lilly Romania SRL. The Saudi National Mental Health Survey was conducted by the King Salman Center for Disability Research. It is funded by Saudi Basic Industries Corporation, King Abdulaziz City for Science and Technology, Ministry of Health (Saudi Arabia), and King Saud University. Funding in-kind was provided by King Faisal Specialist Hospital and Research Centre, the Ministry of Economy and Planning, and the General Authority for Statistics. The Shenzhen Mental Health Survey is supported by the Shenzhen Bureau of Health and the Shenzhen Bureau of Science, Technology, and Information. The Psychiatric Enquiry to General Population in Southeast Spain–Murcia (PEGASUS-Murcia) Project was financed by the Regional Health Authorities of Murcia (Servicio Murciano de Salud and Consejería de Sanidad y Política Social) and Fundación para la Formación e Investigación Sanitarias of Murcia. Dr Laura Helena Andrade is supported by the Brazilian Council for Scientific and Technological Development (CNPq grant 307784/2016-9) and the State of São Paulo Research Foundation (FAPESP; Project Saúde mental, migração e São Paulo Megacity–M3SP; grant 16/50307-3).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Group Information: The WHO World Mental Health Survey collaborators are Sergio Aguilar-Gaxiola, MD, PhD, University of California, Davis; Ali Al-Hamzawi, MD, Al-Qadisiya University; Mohammed Salih Al-Kaisy, MD, Ibn Sina Teaching Hospital; Jordi Alonso, MD, PhD, IMIM-Hospital del Mar Medical Research Institute; Laura Helena Andrade, MD, PhD, Universidade de São Paulo; Lukoye Atwoli, MD, PhD, Moi University; Corina Benjet, PhD, National Institute of Psychiatry Ramón de la Fuente Muñiz; Guilherme Borges, ScD, National Institute of Psychiatry Ramón de la Fuente Muñiz; Evelyn J. Bromet, PhD, Stony Brook University; Ronny Bruffaerts, PhD, Katholieke Universiteit Leuven; Brendan Bunting, PhD, Ulster University; José Miguel Caldas-de-Almeida, MD, PhD, University of Lisbon; Graça Cardoso, MD, PhD; University of Lisbon; Somnath Chatterji, MD, WHO; Alfredo H. Cía, MD, Anxiety Disorders Center; Louisa Degenhardt, PhD, University of New South Wales; Koen Demyttenaere, MD, PhD, Katholieke Universiteit Leuven; Silvia Florescu, MD, PhD, National School of Public Health, Management and Development; Giovanni de Girolamo, MD, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli; Oye Gureje, MD, DSc, FRCPsych, University of Ibadan, Nigeria; Josep Maria Haro, MD, PhD, Parc Sanitari Sant Joan de Déu; Meredith Harris, PhD, The University of Queensland; Hristo Hinkov, MD, PhD, National Center of Public Health and Analyses; Chiyi Hu, MD, PhD, Shenzhen Institute of Mental Health; Peter de Jonge, PhD, University of Groningen; Aimee Nasser Karam, PhD, Institute for Development, Research, Advocacy & Applied Care; Elie G. Karam, MD, St George Hospital University Medical Center; Norito Kawakami, MD, DMSc, The University of Tokyo; Ronald C. Kessler, PhD, Harvard Medical School; Andrzej Kiejna, MD, PhD, University of Lower Silesia; Viviane Kovess-Masfety, MD, PhD, Paris Descartes University; Sing Lee, MB, BS, Chinese University of Hong Kong; Jean-Pierre Lepine, MD, Hôpital Lariboisière–Fernand Widal; John McGrath, MD, PhD, The University of Queensland; Maria Elena Medina-Mora, PhD, National Institute of Psychiatry Ramón de la Fuente Muñiz; Zeina Mneimneh, PhD, University of Michigan; Jacek Moskalewicz, PhD, Institute of Psychiatry and Neurology; Fernando Navarro-Mateu, MD, PhD, Servicio Murciano de Salud; Marina Piazza, MPH, ScD, Instituto Nacional de Salud, Peru; José Posada-Villa, MD, Colegio Mayor de Cundinamarca University; Kate M. Scott, PhD, University of Otago; Tim Slade, PhD, University of Sydney; Juan Carlos Stagnaro, MD, PhD, Universidad de Buenos Aires; Dan J. Stein, FRCPC, PhD, University of Cape Town; Margreet ten Have, PhD, Trimbos-Instituut; Yolanda Torres, MPH, DraHC, CES University; Maria Carmen Viana, MD, PhD, Federal University of Espírito Santo; Daniel V. Vigo, MD, DrPH, University of British Columbia; Harvey Whiteford, MBBS, PhD, University of Queensland; David R. Williams, MPH, PhD, Harvard T.H. Chan School of Public Health; Bogdan Wojtyniak, ScD, National Institute of Public Health-National Institute of Hygiene.

    Disclaimer: The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of the WHO, other sponsoring organizations, agencies, or governments.

    Additional Contributions: We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis.

    Additional Information: A complete list of all within-country and cross-national WMH publications can be found at http://www.hcp.med.harvard.edu/wmh.

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