Patterns of care and dropout rates from outpatient mental healthcare in low-, middle- and high-income countries from the World Health Organization's world mental health survey initiative
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Abstract Background There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries. Methods Respondents from 13 low- or middle-income countries ( N = 60 224) and 15 in high-income countries ( N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan–Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function. Results Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care. Conclusions Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.
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We estimated a 45% dropout and aim to achieve a sample size of 232 participants for a pooled analysis of 7 countries.
“To be on the safe side, considering the dropout rates in previous studies of digital interventions (Moshe et al., 2022) and mental health interventions in low- and middle-income countries (Fernández et al., 2021), we estimated a 45% dropout. Thus, we aim to achieve a sample size of 232 participants for a pooled analysis of 7 countries.”
From Internet-based self-administered intervention to reduce anxiety and depression symptomatology and improve well-being in 7 countries: protocol of a randomized control trial (2024) · cites this paper as Fernández et al., 2021
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Overview and Global Issues in Women’s Behavioral Health
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Treatment coverage for mental disorders
Vigo, D., Harris, M., Munthali, R. J., Kazdin, A. E., Hwang, I. H., Petukhova, M., Sampson, N. A., Aguilar‐Gaxiola, S., Al-Hamzawi, A., Alonso, J., et al. (2025) · doi:10.1093/med/9780198898818.003.0005
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Psychosocial interventions targeting suicidality within inpatient psychiatry: a scoping review
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Validity and Reliability Study of the Moodist Outcome Inventory (MOI)
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- Authors
- Fernández, D., Vigo, D., Sampson, N. A., Hwang, I., Aguilar-Gaxiola, S., Al-Hamzawi, A. O., Alonso, J., Andrade, L. H., Bromet, E. J., de Girolamo, G., de Jonge, P., Florescu, S., Gureje, O., Hinkov, H., Hu, C., Karam, E. G., Karam, G., Kawakami, N., Kiejna, A., Kovess-Masfety, V., Medina-Mora, M. E., Navarro-Mateu, F., Ojagbemi, A., O'Neill, S., Piazza, M., Posada-Villa, J., Rapsey, C., Williams, D. R., Xavier, M., Ziv, Y., Kessler, R. C., & Haro, J. M.
- Affiliations
- Centro de Investigación Biomédica en Red de Salud Mental (ES)
- Harvard University (US)
- University of Al-Qadisiyah (IQ)
- Universitat Pompeu Fabra (ES)
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (BR)
- Stony Brook University (US)
- National School of Public Health, Management and Professional Development (RO)
- University College Hospital, Ibadan (NG)
- National Center of Public Health and Analyses (BG)
- Shenzhen KangNing Hospital (CN)
- University of Balamand (LB)
- The University of Tokyo (JP)
- Wroclaw Medical University (PL)
- Universidad Peruana Cayetano Heredia (PE)
- University of Otago (NZ)
- Universidade Nova de Lisboa (PT)
- Israel Ministry of Health (IL)
- Corresponding author
- Kessler, Ronald C.
- ORCID
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2020-04-28
- Volume
- 51
- Issue
- 12
- Pages
- 2104-2116
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- PMC
- PMC8265313
- OpenAlex
- W3018348673
- Cited by
- 65
- References
- 43
- Citations by year
- 2026: 17 · 2025: 15 · 2024: 6 · 2023: 16 · 2022: 5 · 2021: 6
- FWCI
- 7.39
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Psychological Medicine (publishedVersion, other-oa)
- PubMed (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion, other-oa)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (acceptedVersion, cc-by-nc-nd)
- HAL (submittedVersion)
- Ulster University Research Portal (Ulster University) (submittedVersion, other-oa)
- Repositori digital de la UPF (Universitat Pompeu Fabra) (submittedVersion)
- UPCommons institutional repository (Universitat Politècnica de Catalunya) (submittedVersion, cc-by-nc-nd)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
- Funders
- Robert Wood Johnson Foundation (044708, Grant 044708)
- John D. and Catherine T. MacArthur Foundation (R01 DA016558, R13-MH066849)
- John W. Alden Trust
- Eli Lilly and Company
- Pfizer
- AstraZeneca
- GlaxoSmithKline
- World Health Organization
- University of Michigan
- Ministerio de Ciencia, Innovación y Universidades (RTI2018)
- Royal Society
- European Commission
- Royal Society Te Apārangi (Marsden Grant: E2987-3648., E2987-3648)
- Public Health Agency
- Fundação de Amparo à Pesquisa do Estado de São Paulo
- Generalitat de Catalunya (2017SGR452, 2017-SGR, 2014 SGR 748, 2017 SGR 452; 2014 SGR 748, 2017 SGR 622)
- Bundesministerium für Gesundheit
- National Insurance Institute of Israel
- Ministry of Health, Labour and Welfare (H25-SEISHIN-IPPAN-006, H16-KOKORO-013, H14-TOKUBETSU-026, H13-SHOGAI-023)
- Conselho Nacional de Desenvolvimento Científico e Tecnológico
- Ministerio de Ciencia e Innovación (RTI2018‐100927‐J‐I00)
- 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, CIBER CB06/02/0046, RETICS RD06/0011 REM-TAP, RETICS RD06/0011, RD06/0011, FIS 00/0028, CIBER CB06/02/0046)
- Norway Grants
- European Regional Development Fund (RTI2018-100927-J-I00, RTI2018)
- Consejería de Sanidad y Política Social, Comunidad Autónoma de la Región de Murcia
- Agencia Estatal de Investigación (RTI2018-100927-J-I00)
- 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)
- Topics
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
- Keywords
- treatment discontinuation, mental illness, substance use disorders, low- and middle-income countries, causes of dropout, psychiatric referral, World Mental Health Survey Initiative
- MeSH terms
- Mental Disorders, Health Surveys, Humans, Mental Health Services, Outpatients, Surveys and Questionnaires, World Health Organization, Developed Countries
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