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Cited by 781Mental Health Treatment and AccessHealth disparities and outcomesMigration, Health and Trauma

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

Open access
Evans-Lacko, S., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Benjet, C., Bruffaerts, R., Chiu, W. T., Florescu, S. +24 more·2018·Psychological Medicine
DOI 10.1017/s0033291717003336PMC PMC6878971
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Abstract

Background The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data. Methods Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI). Results Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes). Conclusions The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people. © 2017 Cambridge University Press.

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Registry

Crossref · 10.1017/s0033291717003336

Cites

36 of 36 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

12 of 25 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Disorder characteristics are known to predict treatment.

    “these disorder characteristics are known to predict treatment (Andrade et al. 2014)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Andrade et al. 2014 source

      The Results (page not supplied) show that disorder severity is associated with perceived need for treatment and with reported barriers to seeking it. The paper does not establish that disorder characteristics predict whether someone actually receives treatment; its regression models examine barriers rather than treatment receipt. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
  • Premisecitation

    Socio-economic status is known to have an inverse relationship with these disorder characteristics.

    “SES is known to be inversely related to these disorder characteristics (Scott et al. 2014)”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Scott et al. 2014 source
  • Premisecitation

    Some evidence indicates cross-national differences in how SES relates to mental disorder treatment.

    “there is some evidence of cross-national differences in the association of SES with mental disorder treatment (Kessler et al. 1997; Van Doorslaer & Masseria, 2004; Devaux & De Looper, 2012).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Kessler et al. 1997 source

      The paper’s introductory discussion (section labeled Abstract; page unavailable) contrasts access in Ontario and the United States and says people with limited financial resources face greater barriers in the United States. This supports a possible cross-national socioeconomic difference, but the reported analyses compare treatment by level of need, not the association between SES and treatment across countries. (LLM, conf=0.78)

      Experimental — accuracy not yet measured
    • cites Van Doorslaer & Masseria, 2004 source
    • cites Devaux & De Looper, 2012 source

      Section 4.1 (Doctor visits, paragraph 42) reports that the income gradient in doctor visits differs across countries. But the paper analyzes general health-service use, not mental disorder treatment specifically; its cross-national findings do not establish that narrower claim. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
  • Findingown data

    Bipolar spectrum disorder had significant ORs predicting treatment in the SMH sector (OR=1.2-1.3).

    “And two disorders, social phobia and bipolar spectrum disorder, had significant ORs predicting treatment in the SMH sector (OR=1.2-1.3).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Alcohol use disorder was the only disorder associated with multiple significantly decreased ORs, involving any treatment and treatment in GM and human services sectors (OR=0.6-0.7).

    “Alcohol use disorder was the only disorder associated with multiple significantly decreased ORs, which involved any treatment and treatment in the GM and human services sectors (OR=0.6-0.7)”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 21
  • May combine two claims. 39

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Prior WMH analyses have found models with dummy variables for three and four or more disorders and constant multiplier constraints to be useful.

    “Models of this form have been shpwn to be useful in a number of prior WMH analyses (e.g., Stein et al. 2016; McGrath et al. 2016).”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites Stein et al. 2016 source

      In Results > Predictors of PTSD (page unavailable), Stein et al. use a model in which each additional prior anxiety disorder from zero to three has the same incremental odds ratio. This supports the constant-multiplier aspect, but our copy does not show dummy variables for three and four or more disorders; it says three was the maximum count with enough respondents for a stable estimate. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites McGrath et al. 2016 source

      The Method > Statistical Analysis section describes WMH models with dummy predictors for exactly three and more than three prior disorders, and says these predictors characterize non-additive associations. Our copy does not describe constant multiplier constraints, so it supports the cited example only in part. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Cross-national variation in treatment rates is strongly affected by healthcare spending.

    “cross-national differences in treatment rates are strongly influenced by healthcare spending (Lewer et al. 2015)”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Lewer et al. 2015 source

      The Conclusions say healthcare spending explains some variation in antidepressant use across Europe and is strongly associated with regularity of use; the Results likewise link higher spending to higher odds of regular use. The claim broadens this to treatment rates generally and describes spending as a strong influence, whereas the paper establishes an association, particularly for regular antidepressant use. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The treatment gap is larger for people with low SES and for those in low-income countries, even after adjustment for disorder severity.

    “This gap is even greater for people with low socio-economic status (SES) and those living in low-income countries (Steele et al. 2007; Ormel et al. 2008) even adjusting for disorder severity (Mojtabai, 2010; Andrade et al. 2014).”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Steele et al. 2007 source
    • cites Ormel et al. 2008 source

      The ‘Self-reported disorder prevalence and treatment’ section (page unavailable) reports a larger mental-versus-physical treatment gap in low- and middle-income countries than in high-income countries, including among severely disabling disorders. Our copy does not establish a larger gap for people with low SES. The citing sentence attributes the severity-adjustment clause to other citations, not specifically to Ormel et al.; this paper reports comparisons by severity rather than an adjusted SES finding. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites Mojtabai, 2010

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Research on mental disorder treatment quality finds that low-SES patients are significantly more likely than other patients to receive lower-quality treatment.

    “The small amount of research that exists on mental disorder treatment quality finds that low-SES patients are significantly more likely than other patients to receive lower-quality treatment (Amaddeo & Jones, 2007; Young & Rabiner, 2015).”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites Amaddeo & Jones, 2007 source

      The Introduction and ‘How SES Affects Mental Health Service Use’ discuss psychiatric morbidity, service use, and possible barriers to access for people with lower SES. A search for treatment quality and quality of care found no passage reporting that low-SES patients receive significantly lower-quality treatment. The indexed passages provide no page numbers. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites Young & Rabiner, 2015 source

      The Previous Research section links lower SES to reduced initiation or continuation of child mental health treatment, not to the quality of treatment received. The Results section reports no significant effect of household income on the barriers studied. Searches for SES and treatment quality found no passage establishing the claimed significant difference in treatment quality. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Study design and conductcitation

    Treatment measures were limited to self-reports, which have been found to over-estimate treatment compared to administrative records.

    “Third, the treatment measures were limited to self-reports, which have been found to over-estimate treatment compared to administrative records (Rhodes & Fung, 2004).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Rhodes & Fung, 2004 source

      The Abstract reports that highly distressed people reported more mental-health service use than appeared in their administrative records. But the claim presents overestimation as a general property of self-reported treatment measures; the paper limits the finding to particular groups and notes in the Introduction that people may also under-report use. The paper does not establish that the citing study’s own treatment measures were overestimates. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    Family income was significantly and positively associated with SMH treatment, due to an OR of 0.8 for respondents in each of the three lower income categories relative to the highest income category.

    “was significantly and positively associated with SMH treatment (χ23=8.0, p=.045) due to an OR of 0.8 for respondents in each of the three lower income categories relative to the highest income category.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: The mechanisms by which income and education affect treatment are different.

  • May combine two claims.

    Findingown data

    Disorder type significantly predicted overall treatment and treatment in each service sector.

    “Disorder type was significant in predicting treatment in the base multivariate model predicting overall treatment (χ212=506.1, p<.001) as well as treatment in each service sector (χ212=36.4-315.1, p<.001).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Treatment rate was highest in high-income countries (36.8%), lower in upper-middle-income countries (22.0%), and lowest in lower-middle-income countries (13.7%).

    “The treatment rate was highest in high-income countries (36.8%), lower in upper-middle-income countries (22.0%), and lowest in lower-middle-income countries (13.7%; F2,5366=221.1, p<.001).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Disorder severity had a significant monotonic relationship with each treatment outcome, with severe disorders having highest relative-odds (OR=2.0-2.9), moderate (OR=1.3-1.5), compared to mild.

    “Disorder severity, finally, had a significant monotonic relationship with Each treatment outcome (χ22=21.3-186.0, p<.001), with severe disorders having highest relative-odds (OR=2.0-2.9) followed by moderate disorders (OR=1.3-1.5) compared to mild disorders.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Respondents with the highest SES had a somewhat greater likelihood of receiving any treatment, but this pattern was mainly confined to specialty mental health treatment.

    “Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Education had a modest but stronger association with treatment than income did.

    “The modest, but nonetheless stronger, association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The 3-way interactions were significant for both education and income predicting any treatment and for income predicting GM treatment.

    “The 3-way interactions were significant for both education and income predicting any treatment (χ212=22.9-29.8, p=.029-.003) and for income predicting GM treatment (χ212=26.8, p=.008).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Across sectors, treatment was most common in GM, followed by SMH, and much lower in human services and CAM.

    “treatment was consistently most common in the GM sector followed by the SMH sector and much lower in the human services and CAM sectors.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The 4-category measures of respondent education and income were significantly correlated (polychoric correlation = 0.295, p < .001).

    “The 4-category measures of respondent education and income were significantly correlated with each other (polychoric correlation = 0.295, p = <.001; see Appendix Table 2 for within-survey distributions and associations).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Within specialty mental health treatment, education was positively associated with treatment, with the highest treatment rate among the most educated and only a weak education-treatment association among other respondents.

    “where the association was positive with education (highest treatment among respondents with highest education and a weak association of education with treatment among other respondents)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Within specialty mental health treatment, income showed a non-monotonic association with treatment: middle-income respondents had somewhat lower treatment rates, while high- and low-income respondents had equivalent rates.

    “but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The sum of sector-specific treatment rates (38.7 per 100) exceeded the 29.0% with any treatment because some patients were treated in multiple sectors.

    “The sum of sector-specific treatment rates (38.7/100 respondents) exceeded the 29.0% of individuals with any treatment due to some patients being treated in multiple sectors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The highest treatment rate across surveys was in Murcia, Spain (49.6%) and the lowest in Shenzhen, PRC (6.7%).

    “The highest treatment rate across surveys was in Murcia, Spain (49.6%) and the lowest in Shenzhen in the People’s Republic of China (PRC; 6.7%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among 12-month DSM-IV/CIDI cases, the treated proportion was 13.7% in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries.

    “Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Education was most consistently associated with SMH treatment, while associations of education with treatment in other service sectors were relatively weak (ORs 0.6-0.8).

    “Education, in comparison, was most consistently associated with SMH treatment, as the associations of education with treatment in other service sectors were relatively weak (significant ORs in the range 0.6-0.8).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The 2-way interactions of income with severity and with country income level were significant in a model excluding 3-way interactions in predicting SMH treatment.

    “The 2-way interactions of income with severity and with country income level were significant in a model that excluded the 3-way interactions in predicting SMH treatment (χ26=12.9-13.6, p=.045-.035).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The non-significant association of income with any treatment in the total sample masked a significantly negative association among mild cases in upper-middle-income countries (OR=1.8 for low-income respondents).

    “and a significantly negative association among mild cases in upper-middle-income countries (a significant OR=1.8 for low-income respondents; χ23=14.9, p=.002).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The association of education with SMH treatment was stable across all levels of disorder severity and country income groups, with the significant association due to comparatively high odds of treatment among people at the highest education level (ORs 0.6-0.7 for lower education levels, equivalent to 1.4-1.7 higher odds at highest versus lower levels).

    “The association of education with SMH treatment was stable across all levels of disorder severity and country income groups, with the significant association due to a comparatively high odds of treatment among people at the highest education level (ORs of 0.6-0.7 for lower education levels equivalent to 1.4-1.7 higher odds at highest versus lower levels).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Subgroup analysis found no significant association of income with overall treatment in the total sample and only inconsistent opposite-sign associations in subsamples.

    “Subgroup analysis found no significant association of income with overall treatment in the total sample and only inconsistent opposite-sign associations in subsamples.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The significant association of income with SMH treatment in the total sample was consistent across country income groups due to especially low odds of treatment in intermediate income groups within each severity subsample (OR=0.3-0.5) rather than in the lowest income group (OR=0.7-0.9).

    “The significant association of income with SMH treatment in the total sample was consistent across country income groups due to especially low odds of treatment in intermediate income groups within each severity subsample (OR=0.3-0.5) rather than in the lowest income group (OR=0.7-0.9).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The non-significant association of income with GM treatment in the total sample masked a significantly positive association among moderately severe cases in lower-middle income countries and mild cases in both lower-middle and high income countries (ORs 0.2-0.7).

    “The non-significant association of income with GM treatment in the total sample, finally, was found to mask a significantly positive association among moderately severe cases in lower-middle income countries and mild cases in both lower-middle and high income countries (significant ORs of 0.2-0.7; χ23=8.8-18.3, p=.032-<.001)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The significant association of education with any treatment in the total sample was limited to severe and moderate cases in high-income countries, with significant ORs among lower education respondents in the range 0.5-0.8.

    “Subgroup analysis showed that the significant association of education with any treatment in the total sample was limited to severe and moderate cases in high-income countries (χ23=9.9-17.2, p=.019-.001). Significant ORs among respondents with lower levels of education were in the range 0.5-0.8.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The non-significant association of income with GM treatment in the total sample masked significantly negative associations among mild cases in upper-middle-income countries and severe cases in high income countries (ORs 1.5-2.0).

    “and significantly negative associations among mild cases in upper-middle-income countries and severe cases in high income countries (significant ORs of 1.5-2.0; χ23=15.1-44.3,, p=.002-<.001).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Although income was not significantly associated with GM treatment in the total sample, a significant 3-way interaction was found due to a series of opposite-sign subgroup associations with no apparent patterning.

    “Although the association of income with GM treatment was non-significant in the total sample, a significant 3-way interaction was found due to a series of opposite-sign subgroup associations that had no apparent patterning.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The significant association of education with SMH treatment in the total sample varied by disorder severity and country income, with significant ORs among lower education respondents in the range 0.6-0.7.

    “The significant association of education with SMH treatment in the total sample varied by disorder severity and country income, with significant ORs among respondents of lower education were in the range 0.6-0.7.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The income discrepancy in sector was small: highest income category had only about 25% higher odds of SMH treatment than lower income categories, and there were no differences in odds of receiving SMH treatment across the lower three income categories.

    “This discrepancy was small, though, as cases in the highest income category (roughly one-fourth of the population) had only about 25% higher odds of specialty mental health treatment than those in lower income categories and, as noted in the prior paragraph, there were no differences in odds of receiving specialty treatment across the lower three income categories.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The sampling design used multi-stage clustered area probability households.

    “The samples were based on a multi-stage clustered area probability household design.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The CIDI translation, back-translation, adaptation, and harmonization protocol required bilingual clinicians with cultural competence to review, modify, and approve symptom-describing phrases.

    “The CIDI interview translation, back-translation, adaptation, and harmonization protocol required culturally competent bilingual clinicians to review, modify, and approve key phrases describing symptoms (Harkness et al. 2008).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Harkness et al. 2008

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductcitation

    Mental disorders were assessed using the WHO Composite International Diagnostic Interview (CIDI) Version 3.0, a fully structured interview that yields lifetime and 12-month prevalence estimates for common DSM-IV disorders.

    “Mental disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI) Version 3.0 (Kessler & Ustun, 2004), a fully-structured interview generating lifetime and 12-month prevalence estimates of common DSM-IV disorders.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Kessler & Ustun, 2004 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Blinded clinical reappraisal interviews using the Structured Clinical Interview for DSM-IV in several WMH surveys showed generally good agreement with CIDI diagnoses.

    “Blinded clinical reappraisal interviews with the Structured Clinical Interview for DSM-IV (First et al. 2002) in a number of WMH surveys found generally good concordance with diagnoses based on the CIDI (Haro et al. 2006).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Haro et al. 2006 source

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    Weights corrected for under-sampling of Part I respondents without disorders, within-household selection probabilities, and residual sample-population differences on Census demographic-geographic variables.

    “Weights adjusted for under-sampling Part I respondents without disorders, differences in within-household probabilities of selection (due to the selection of only one respondent per household no matter the number of eligible residents), and residual discrepancies between sample and population distributions on Census demographic-geographic variables.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Survey response rates ranged from 45.9% to 97.2%, with a sample-size-weighted average of 70.1% under the AAPOR RR1w definition.

    “Response rates were 45.9-97.2% across surveys with a weighted (by sample size) average of 70.1% using the American Association for Public Opinion research RR1w definition (AAPOR, 2016).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites AAPOR, 2016

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    In 25 countries, the surveys used samples intended to represent adult household residents.

    “The surveys were administered to representative samples of adult household residents in 25 countries.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The sample contained no countries classified as low-income.

    “There were no low-income countries in the sample.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Nineteen surveys were nationally representative; three represented all urbanized areas; the remaining surveys represented selected regions or metropolitan areas.

    “Samples were nationally representative in 19 surveys, representative of all urbanized areas in 3 others (Colombia, Mexico, Peru), and representative of selected regions (Nigeria) or Metropolitan areas (Sao Paulo in Brazil, Medellin in Colombia, a series of cities in Japan, Beijing/Shanghai and Shenzhen in the Peoples Republic of China) in the others.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The models adjusted for respondent age, sex, and marital status.

    “Our models controlled for respondent age, sex, and marital status.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Confidence intervals for prevalence estimates and odds ratios were computed with Taylor series linearization in SUDAAN to account for weighting and geographic clustering.

    “Confidence intervals for prevalence estimates and ORs were estimated using the Taylor series linearization method (Wolter, 1985) implemented in the SUDAAN software system (Research Triangle Institute, 2002) to adjust for weighting and geographic clustering of data.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Wolter, 1985

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Research Triangle Institute, 2002

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The model controlled adequately for disorder characteristics so that estimates of SES effects on treatment would be accurate.

    “making it important to control adequately for these characteristics to obtain accurate estimates of effects of SES on treatment.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Because of the large number of tests, over-fitting was possible, so results should be considered exploratory.

    “Even with these global tests, though, over-fitting was possible due to the large number of tests, making it important to consider results only exploratory.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Part II data were weighted to correct for under-sampling of Part I non-cases, so weighted Part II prevalence estimates matched Part I estimates.

    “Part II data were weighted to adjust for the under-sampling of Part I non-cases, making weighted Part II prevalence estimates identical to Part I estimates.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Even though people of different financial means were equally likely to receive some type of treatment, a significant discrepancy existed in the sector in which treatment was received.

    “However, the significant positive association with specialty mental health treatment and the significant inverse association with human services treatment in the total sample showed that even though people of different financial means were equally likely to receive some type of treatment, a significant discrepancy existed in the sector in which treatment was received.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Survey response might have been related to social status, presence and severity of mental disorders or treatment in ways that were uncorrected by post-stratification adjustments.

    “Although we attempted to control for differential response through post-stratification adjustments, survey response might have been related to social status, presence and severity of mental disorders or treatment in ways that were uncorrected.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    Because the number of countries was small (n=25) and no information was available about within-country geographic characteristics in most surveys, there were too few geographic units to carry out quantitative analyses of other contextual factors.

    “However, as the number of countries was small (n = 25) and no information was available about within-country geographic characteristics in most surveys, we had too few geographic units of analysis to carry out quantitative analyses of other contextual factors.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    In the total sample, low SES had an especially low rate of treatment only for SMH treatment, and income was inversely related to HS treatment, so income was related more to sector of treatment than to whether treatment was received.

    “We also broadly confirmed previous evidence that people with low SES have an especially low rate of treatment, although in the total sample this was true only for SMH treatment and income was inversely related to HS treatment, resulting in income being related more to sector of treatment than to whether or not treatment was received.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductcitation

    Validity of disorder measures, although good in WMH surveys where assessed, was not assessed in all surveys and might have varied with SES.

    “validity, although good in the WMH surveys were it was assessed (Haro et al. 2006), was not assessed in all surveys and might have varied with SES.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Haro et al. 2006 source

  • May combine two claims.

    Interpretationown data

    The significant associations of SES with treatment were most consistent in predicting SMH treatment, but they were less strong than anticipated.

    “The significant associations of SES with treatment were most consistent in predicting SMH treatment, but they were less strong than anticipated.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Duration was not measured for the disorders that were assessed.

    “duration was not measured for the disorders that were assessed”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    The sample of countries was non-representative and the response rate varied widely across countries.

    “First, the sample was limited in that the sample of countries was non-representative and the response rate varied widely across countries.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Self-reports only assessed number of visits rather than treatment quality.

    “In addition, these self-reports only assessed number of visits rather than treatment quality.”
    Quote in the paperNot a substantial claim
54 of 54

  • The authors state this as an assumption.

    For respondents with two disorders, the added predictive effect of each individual disorder is multiplicative.

    “The incremental predictive effects of individual disorders among people with 2 disorders were then assumed to be multiplicative; that is, if the OR associated with Disorder X was 1.5, we would expect respondents with exactly 1 other disorder would have a 1.5 increased odds of obtaining treatment in the presence versus absence of Disorder X.”

  • The authors state this as an assumption.

    The odds ratio for a given disorder is the same across all combinations of that disorder with exactly one other disorder.

    “This specification imposed parsimony on the data by constraining the OR of Disorder X to be the same across all 11 combinations of Disorder X with exactly l other disorder”

  • The authors state this as an assumption.

    The 3-way and higher-order interactions among disorders predicting treatment were subject to a constant multiplier that could be 1.0 or different from 1.0.

    “The dummy variables for 3 and 4+ disorders imposed additional constraints by assuming that the 3-way and higher-order interactions among disorders predicting treatment were subject to a constant multiplier that could be 1.0 (i.e., the interactions were strictly multiplicative) or different from 1.0.”

  • The authors state this as an assumption.

    The mechanisms by which income and education affect treatment are different.

    “We considered it appropriate to include both, though, as the mechanisms involved in the two are presumably different.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Education's specialty-treatment association is described as both varying and stable

    Minor

    The results say the education-specialty-treatment association varied by disorder severity and country income, while the discussion says it was stable across those same groups.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 6

  1. 2009, World Bank List of Economies (July 2009)
  2. 2002, SUDAAN: Professional Software for Survey Data Analysis [Computer Program]
  3. 2016, Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys
  4. First, 2002, Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-Patient Edition. (SCID-I/NP)
  5. Harkness, 2008, The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders, 91
  6. 2012, Global Burden of Mental Disorders and the Need for A Comprehensive, Coordinated Response From Health and Social Sectors at the Country Level

Cited by

Sorted by citations

Related

Authors
Evans-Lacko, S., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Benjet, C., Bruffaerts, R., Chiu, W. T., Florescu, S., de Girolamo, G., Gureje, O., Haro, J. M., He, Y., Hu, C., Karam, E. G., Kawakami, N., Lee, S., Lund, C., Kovess-Masfety, V., Levinson, D., Navarro-Mateu, F., Pennell, B. E., Sampson, N. A., Scott, K. M., Tachimori, H., ten Have, M., Viana, M. C., Williams, D. R., Wojtyniak, B. J., Zarkov, Z., Kessler, R. C., Chatterji, S., & Thornicroft, G.
Affiliations
  • King's College London (GB)
  • University of Al-Qadisiyah (IQ)
  • Universitat Pompeu Fabra (ES)
  • Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz (MX)
  • KU Leuven (BE)
  • Harvard University (US)
  • National School of Public Health, Management and Professional Development (RO)
  • University College Hospital, Ibadan (NG)
  • Centro de Investigación Biomédica en Red de Salud Mental (ES)
  • Shanghai Jiao Tong University (CN)
  • Shenzhen KangNing Hospital (CN)
  • University of Balamand (LB)
  • The University of Tokyo (JP)
  • Chinese University of Hong Kong (HK)
  • University of Cape Town (ZA)
  • Israel Ministry of Health (IL)
  • University of Michigan (US)
  • University of Otago (NZ)
  • National Center of Neurology and Psychiatry (JP)
  • Universidade Federal do Espírito Santo (BR)
  • Narodowy Instytut Zdrowia Publicznego PZH – Państwowy Instytut Badawczy (PL)
  • National Center of Public Health and Analyses (BG)
  • World Health Organization (CH)
Corresponding author
Kessler, R. C.
ORCID
Venue
Psychological Medicine
Publisher
Cambridge University Press (CUP)
Published
2017-11-27
Volume
48
Issue
9
Pages
1560-1571
ISSN
  • 0033-2917 (ISSN-L)
  • 1469-8978
DOI
10.1017/s0033291717003336
PMC
PMC6878971
OpenAlex
W2766194567
Semantic Scholar
d18855ad1dcd6dbf240bfdef5f70607523fa0ee3
Cited by
781
References
35
Citations by year
2026: 110 · 2025: 164 · 2024: 179 · 2023: 145 · 2022: 123 · 2021: 26 · 2020: 18 · 2019: 10 · 2018: 4
FWCI
12.53
Type
journal article
Language
en
Open access
Licence
www.cambridge.org/core/terms (unspecified)
Locations
  • Psychological Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • RECERCAT (Consorci de Serveis Universitaris de Catalunya) (acceptedVersion)
  • London School of Economics and Political Science Research Online (London School of Economics and Political Science) (submittedVersion)
  • London School of Economics and Political Science Theses Online (London School of Economics and Political Science) (submittedVersion)
  • Dipòsit Digital de la Universitat de Barcelona (Universitat de Barcelona) (submittedVersion, public-domain)
  • Research Portal (King's College London) (submittedVersion, other-oa)
  • University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
  • Repositori digital de la UPF (Universitat Pompeu Fabra) (submittedVersion)
Funders
  • Robert Wood Johnson Foundation (044708, Grant 044708)
  • John D. and Catherine T. MacArthur Foundation (R01 DA016558, R13-MH066849)
  • John W. Alden Trust
  • Bristol-Myers Squibb
  • Eli Lilly and Company
  • Pfizer
  • AstraZeneca
  • GlaxoSmithKline
  • World Health Organization
  • University of Michigan
  • South London and Maudsley NHS Foundation Trust
  • King's College Hospital NHS Foundation Trust
  • Universidad CES
  • National Institute for Health and Care Research (FP7/2007–2013)
  • King's College London
  • European Commission (EAHC 20081308, 20081308, 2007–2013, FP7 2007-2013, QLG5–1999-01042, SANCO2004123, 2004123, FP7/2007)
  • Public Health Agency
  • Fundação de Amparo à Pesquisa do Estado de São Paulo (03/00204-3, 03/00204?)
  • Generalitat de Catalunya (01042)
  • Bundesministerium für Gesundheit
  • National Insurance Institute of Israel
  • Ministry of Health, Labour and Welfare (H25-SEISHIN-IPPAN-006, H13-SHOGAI-023)
  • Universidade de Lisboa
  • Ministerio de Ciencia y Tecnología (SAF 2000 158-CE)
  • Fundación para la Formación e Investigación Sanitarias de la Región de Murcia
  • Servicio Murciano de Salud
  • Regione Piemonte (00/0028)
  • Fakultet Medicinskih Nauka, Univerziteta U Kragujevcu
  • Servier
  • H. Lundbeck A/S
  • Fundação Champalimaud (R01 MH070884)
  • Ministerio de Salud
  • Ministerstwo Zdrowia
  • National Institutes of Health (5r13mh066849-04, 5r01mh069864-04, 5r01mh070884-05)
  • Substance Abuse and Mental Health Services Administration
  • U.S. Public Health Service (R01-DA016558, R13‐MH066849, R01- MH069864)
  • Pfizer Foundation (R01‐MH069864, R01-DA016558, R13-MH066849, R03-TW006481)
  • Pan American Health Organization
  • Executive Agency for Health and Consumers
  • Fundação para a Ciência e a Tecnologia
  • Instituto de Salud Carlos III (CB06/02/0046, RETICS RD06/0011, RD06/0011, FIS 00/0028, CIBER CB06/02/0046)
  • Norway Grants
  • Consejería de Sanidad y Política Social, Comunidad Autónoma de la Región de Murcia
  • Departament de Salut, Generalitat de Catalunya
  • National Institute of Mental Health (R13-MH-066849, R01‐MH070884, R01MH061905, R01MH059575, MH60220, MH070884, U01MH060220, R01‐MH069864)
  • National Institute on Drug Abuse (R01DA016558)
  • Fogarty International Center (FIRCA R03TW006481, R03TW006481)
  • FP7 Ideas: European Research Council (337673)
Topics
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Social Sciences › Health › Health disparities and outcomes
  • Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
Keywords
mental health treatment gap, socioeconomic status, anxiety disorders, mood disorders, substance use disorders, income, mental health services, financial barriers, low- and middle-income countries
MeSH terms
Adolescent, Adult, Aged, Aged, 80 and over, Mental Disorders, Developing Countries, Female, Health Surveys, Humans, Male, Mental Health, Middle Aged, Patient Acceptance of Health Care, Psychotherapy, Socioeconomic Factors, Multivariate Analysis, Logistic Models, Developed Countries, Internationality, Healthcare Disparities, Young Adult

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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