Determinants of effective treatment coverage for posttraumatic stress disorder: findings from the World Mental Health Surveys
verfasst von:
Dan J. Stein, Alan E. Kazdin, Richard J. Munthali, Irving Hwang, Meredith G. Harris, Jordi Alonso, Laura Helena Andrade, Ronny Bruffaerts, Graça Cardoso, Stephanie Chardoul, Giovanni de Girolamo, Silvia Florescu, Oye Gureje, Josep Maria Haro, Aimee N. Karam, Elie G. Karam, Viviane Kovess-Masfety, Sing Lee, Maria Elena Medina-Mora, Fernando Navarro-Mateu, José Posada-Villa, Juan Carlos Stagnaro, Margreet ten Have, Nancy A. Sampson, Ronald C. Kessler, Daniel V. Vigo, on behalf of the WHO World Mental Health Survey Collaborators
Posttraumatic stress disorder (PTSD) is associated with significant morbidity, but efficacious pharmacotherapy and psychotherapy are available. Data from the World Mental Health Surveys were used to investigate extent and predictors of treatment coverage for PTSD in high-income countries (HICs) as well as in low- and middle-income countries (LMICs).
Methods
Seventeen surveys were conducted across 15 countries (9 HICs, 6 LMICs) by the World Health Organization (WHO) World Mental Health Surveys. Of 35,012 respondents, 914 met DSM-IV criteria for 12-month PTSD. Components of treatment coverage analyzed were: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) effective treatment coverage. Regression models investigated predictors of treatment coverage.
Results
12-month PTSD prevalence in trauma exposed individuals was 1.49 (S.E., 0.08). A total of 43.0% (S.E., 2.2) received any mental health services, with fewer receiving adequate pharmacotherapy (13.5%), adequate psychotherapy (17.2%), or effective treatment coverage (14.4%), and with all components of treatment coverage lower in LMICs than HICs. In a multivariable model having insurance (OR = 2.31, 95 CI 1.17, 4.57) and severity of symptoms (OR = .35, 95% CI 0.18, 0.70) were predictive of effective treatment coverage.
Conclusion
There is a clear need to improve pharmacotherapy and psychotherapy coverage for PTSD, particularly in those with mild symptoms, and especially in LMICs. Universal health care insurance can be expected to increase effective treatment coverage and therefore improve outcomes.
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Introduction
Posttraumatic stress disorder (PTSD) is a prevalent disorder throughout the world, and is associated with significant morbidity [1, 2]. PTSD leads to individual suffering, reduced quality of life, and considerable societal costs [3, 4]. Fortunately, there is a growing evidence-base of efficacious treatments for this condition, including various forms of psychotherapy and pharmacotherapy [5, 6]. Treatment guidelines for PTSD have been developed by several professional organizations to encourage evidence-based interventions, with most guidelines advocating both pharmacotherapy and psychotherapy as first-line interventions [7, 8]. Data from the WHO World Mental Health Surveys have emphasized that the delay in treatment seeking for mental disorders is a global problem [9], and that there is a treatment gap for a range of these conditions, including anxiety disorders and PTSD [10].
Although contact coverage (the percentage of people in need that get any service) is an important indicator, effective coverage (the percentage that get good care and obtain health benefits) is particularly relevant to health system performance assessment [11, 12]. Determining the extent and predictors of effective coverage for PTSD is an important first step towards developing appropriate strategies to address obstacles to care. While some structural and attitudinal barriers have received attention [13], a number of others, including symptom severity and health insurance have not. The focus on universal health coverage in the Sustainable Developmental Goals further emphasizes the need to investigate effective coverage [14]. A small literature on effective coverage indicators in the area of mental health has emerged, and relies on a number of different methods including need assessment strategies, utilization assessment strategies, and quality assessment strategies [12, 15]. The recent development of an “effective treatment coverage” indicator that quantifies utilization, but also adjusts for quality of care and user adherence, facilitates such work [16].
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The WHO World Mental Health Survey Initiative provides a valuable dataset for more detailed investigations of effective treatment coverage across the world, so providing an important foundation for work on addressing key barriers to care and scaling up interventions [16, 17]. We investigated the extent and predictors of treatment coverage for PTSD in individuals who met DSM-IV criteria for 12-month PTSD in a range of high-income countries (HICs) as well as low- and middle-income countries (LMICs). Components of treatment coverage analyzed were: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) effective treatment coverage (adequate severity-specific use of pharmacotherapy and/or psychotherapy).
Methods
Sample
The WHO World Mental Health Surveys (WMHS) include 17 community surveys with 35,012 adults across 15 countries, including six classified by the World Bank as low- or middle-income countries (LMICs) and nine classified as high-income countries (HICs) [18]. All samples were based on multi-stage clustered area probability household designs. Samples were nationally representative in 11 surveys, representative of all urbanized areas in two others, and representative of selected regions or Metropolitan areas in the others [18] (Table 1).
Table 1
WMH sample characteristics by World Bank income categoriesaCountry
Surveyb
Sample characteristicsc
Field dates
Age range
Sample size
Response rated
Part I
Part II
I. Low and Middle-income countries
Brazil – São Paulo
São Paulo Megacity
São Paulo metropolitan area
2005–8
18–93
5037
2942
81.3
Colombia
NSMH
All urban areas of the country (approximately 73% of the total national population).
2003
18–65
4426
2381
87.7
Colombia – Medellín
MMHHS
Medellin metropolitan area
2011–12
19–65
3261
1673
97.2
Lebanon
LEBANON
Nationally representative.
2002–3
18–94
2857
1031
70.0
Mexico
M-NCS
All urban areas of the country (approximately 75% of the total national population).
2001–2
18–65
5782
2362
76.6
Nigeria
NSMHW
21 of the 36 states in the country, representing 57% of the national population. The surveys were conducted in Yoruba, Igbo, Hausa and Efik languages.
2002–4
18–100
6752
2143
79.3
Romania
RMHS
Nationally representative.
2005–6
18–96
2357
2357
70.9
Total
(30472)
(14889)
80.1
II. High-income countries
Argentina
AMHES
Eight largest urban areas of the country (approximately 50% of the total national population)
2015
18–98
3927
2116
77.3
Belgium
ESEMeD
Nationally representative. The sample was selected from a national register of Belgium residents.
2001–2
18–95
2419
1043
50.6
France
ESEMeD
Nationally representative. The sample was selected from a national list of households with listed telephone numbers.
2001–2
18–97
2894
1436
45.9
Germany
ESEMeD
Nationally representative.
2002–3
19–95
3555
1323
57.8
Italy
ESEMeD
Nationally representative. The sample was selected from municipality resident registries.
2001–2
18–100
4712
1779
71.3
Netherlands
ESEMeD
Nationally representative. The sample was selected from municipal postal registries.
2002–3
18–95
2372
1094
56.4
Portugal
NMHS
Nationally representative.
2008–9
18–81
3849
2060
57.3
Spain
ESEMeD
Nationally representative.
2001–2
18–98
5473
2121
78.6
Spain – Murcia
PEGASUS- Murcia
Murcia region. Regionally representative.
2010–12
18–96
2621
1459
67.4
United States
NCS-R
Nationally representative.
2001–3
18–99
9282
5692
70.9
Total
(41104)
(20123)
64.4
III. Totale
(71576)
(35012)
70.3
aThe World Bank (2012) Data. Accessed May 12, 2012 at: http://data.worldbank.org/country. Some of the WMH countries have moved into new income categories since the surveys were conducted. The income groupings above reflect the status of each country at the time of data collection. The current income category of each country is available at the preceding URL
bNSMH (The Colombian National Study of Mental Health); MMHHS (Medellín Mental Health Household Study); LEBANON (Lebanese Evaluation of the Burden of Ailments and Needs of the Nation); M-NCS (The Mexico National Comorbidity Survey); NSMHW (The Nigerian Survey of Mental Health and Wellbeing); RMHS (Romania Mental Health Survey); AMHES (Argentina Mental Health Epidemiologic Survey); ESEMeD (The European Study Of The Epidemiology Of Mental Disorders); NMHS (Portugal National Mental Health Survey); PEGASUS-Murcia (Psychiatric Enquiry to General Population in Southeast Spain-Murcia);NCS-R (The US National Comorbidity Survey Replication)
cMost WMH surveys are based on stratified multistage clustered area probability household samples in which samples of areas equivalent to counties or municipalities in the US were selected in the first stage followed by one or more subsequent stages of geographic sampling (e.g., towns within counties, blocks within towns, households within blocks) to arrive at a sample of households, in each of which a listing of household members was created and one or two people were selected from this listing to be interviewed. No substitution was allowed when the originally sampled household resident could not be interviewed. These household samples were selected from census area data in all countries other than France (where telephone directories were used to select households) and the Netherlands (where postal registries were used to select households). Several WMH surveys (Belgium, Germany, Italy, Spain-Murcia) used municipal, country resident or universal health-care registries to select respondents without listing households. 10 of the 17 surveys are based on nationally representative household samples
dThe response rate is calculated as the ratio of the number of households in which an interview was completed to the number of households originally sampled, excluding from the denominator households known not to be eligible either because of being vacant at the time of initial contact or because the residents were unable to speak the designated languages of the survey. The weighted average response rate is 70.3%
eThe following surveys, included in Thornicroft et al., 2016,10 were excluded from this study due to lack of data on the specific drug taken and on adherence to prescribed dosage: Beijing/Shanghai, Bulgaria, Iraq, Israel, Japan, and Peru
Surveys were approved by the review boards of the coordinating organizations, which monitored adherence with procedures for informed consent [19]. Interviews were carried out face-to-face in respondents’ homes by trained lay interviewers. Field training and quality control procedures are described elsewhere [19]. Respondents were aged 18+ in all surveys other than one (19+ in Medellin, Colombia) and had unrestricted upper age limits in most surveys. The average response rate weighted by sample size was 70.3% using the American Association for Public Opinion Research RR1w definition [20].
To reduce respondent burden, interviews were divided into two parts [21]. Part I, administered to all respondents, assessed core mental disorders. Part II assessed additional disorders and correlates and was administered to all respondents with any Part I disorder plus a probability subsample of other Part I respondents. Part II data were weighted to adjust for the under-sampling of Part I non-cases [21]. In total, 71,576 Part I and 35,012 Part II respondents were interviewed. Of these 35,012 respondents, 914 met DSM-IV criteria for 12-month PTSD (Table 2).
Table 2
Sociodemographic distribution of the sample by country-income level, among those with 12-month posttraumatic stress disorder
All countries (n = 914)
High income countries (n = 694)
Low/ middle income countries (n = 220)
%/ Mean
(SE)
%/ Mean
(SE)
%/ Mean
(SE)
Gender
Male
22.7
(1.7)
23.5
(1.8)
20.3
(4.3)
Female
77.3
(1.7)
76.5
(1.8)
79.7
(4.3)
Age Group
18–29
25.3
(1.9)
22.8
(2.0)
32.7
(4.9)
30–44
31.0
(2.0)
28.9
(2.0)
37.6
(5.0)
45–59
31.8
(2.0)
35.4
(2.2)
21.0
(4.4)
60+
11.9
(1.5)
12.9
(1.9)
8.7
(2.3)
Marital status
Separated, divorced, or widowed
23.9
(1.7)
26.1
(1.9)
17.0
(3.1)
Never married
22.0
(1.9)
21.8
(2.0)
22.8
(4.5)
Married or cohabitating
54.1
(2.1)
52.1
(2.3)
60.1
(4.5)
Income
Low
35.0
(2.2)
35.6
(2.5)
32.9
(4.5)
Low-Average
24.1
(1.9)
22.8
(2.0)
28.0
(5.1)
Average-High
23.6
(1.9)
25.0
(2.3)
19.1
(3.7)
High
17.4
(1.8)
16.5
(1.9)
20.0
(4.0)
Education
Low
20.5
(1.7)
21.2
(2.0)
18.5
(3.4)
Low-Average
35.4
(2.4)
37.4
(2.9)
29.0
(4.6)
Average-High
27.0
(2.0)
24.8
(2.2)
33.6
(4.6)
High
17.2
(1.7)
16.6
(2.0)
19.0
(3.5)
Insurance
Any Insurance (Yes)
83.9
(1.7)
90.3
(1.3)
64.3
(5.0)
Direct Private/Optional Insurance (Yes)
16.0
(1.7)
20.1
(2.2)
3.4
(1.3)
Employment Status
Homemaker
13.4
(1.5)
7.6
(1.1)
31.3
(4.4)
Other
20.2
(1.8)
21.5
(2.2)
16.1
(2.9)
Retired
10.5
(1.3)
12.1
(1.6)
5.6
(1.9)
Student
2.4
(0.8)
2.0
(0.8)
3.6
(2.0)
Working
53.5
(2.1)
56.8
(2.3)
43.4
(4.6)
Severity
Mild
24.0
(2.4)
21.7
(2.6)
31.2
(5.1)
Moderate
35.1
(2.1)
37.8
(2.3)
26.9
(4.2)
Severe
40.9
(2.2)
40.5
(2.6)
41.9
(4.6)
Survey Yeara
Continuous
2.9
(0.2)
2.4
(0.2)
4.5
(0.3)
aSurvey year is continuous, so the mean is shown instead of %
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Measures and data analysis
The interview schedule used in WMH was the WHO Composite International Diagnostic Interview (CIDI) Version 3.0 [22], a fully-structured interview generating lifetime and 12-month prevalence estimates of common DSM-IV disorders that includes stringent protocols of translation, back-translation, expert review, adaptation, and harmonization across sites [23]. Blinded clinical reappraisal interviews with the Structured Clinical Interview for DSM-IV had good concordance with diagnoses based on the CIDI [24]. Respondents with PTSD were considered severe either if their symptoms resulted in severe role impairment (7–10 points) according to the Sheehan Disability Scale [25], moderate if they reported moderate role impairment in the SDS (4–6), and mild if they reported no or moderate role impairment (3 or less).
We classified health treatment providers into two categories: (1) specialist mental health (SMH; psychiatrist, psychologist, other mental health professional in any setting, social worker or counselor in a mental health specialized setting); and (2) general medical (GM; primary care doctor, other medical doctor, any other healthcare professional seen in a GM setting) [18]. Respondents were asked about number of visits with each type of provider in the past 12 months and, for medical providers, about whether they provided psychotherapy, pharmacotherapy, or both. Specific type, dose, and duration were recorded for each psychotropic medication used in the past 12 months. Further details about the treatment variables are presented elsewhere [26].
Consistent with our previous work [18], a series of summary variables was created from these detailed respondent reports. Contact coverage involved any 12-month contact with a specialist or general medical provider for a mental health condition. For the pharmacotherapy measures two clinical psychiatrists with expertise in public health (DV, CSW) independently reviewed responses about medications used (which involved selecting from country specific lists including generic and brand names) and classified them. Discrepancies were reconciled by consensus.
As described in our previous work [18], Adequate medication control required at least four physician visits [26]. Medication adherence required taking the prescribed daily dose at least 90% of the time during the past 12 months of pharmacotherapy (e.g., at least 27 out 30 days in a month) [27‐29]. Adequate pharmacotherapy required taking an antidepressant with adequate medication control and adherence. While some PTSD guidelines have recommended only specific antidepressants, others have made broader recommendations [7]. A small fraction of people with PTSD may avoid antidepressants due to side effects, failed trials, or other legitimate reasons, so if a non-antidepressant psychotropic was adequately controlled by a psychiatrist with adequate patient adherence, it was also considered adequate.
In congruence with our previous work [30], Any psychotherapy required having two or more visits to any specialty mental health provider among help seekers. Adequate number of sessions required at least eight sessions. Adequate psychotherapy required at least 8 sessions from an adequate provider or still being in treatment after 2 visits. In the case of psychiatrists, for an encounter to be considered as a psychotherapeutic intervention (as opposed to medication adjustment), visits needed to last 30 minutes or more. PTSD guidelines emphasize the efficacy of trauma-focused therapies, but some make more specific recommendations, while others recommend broader classes of psychotherapy [7]. We chose “at least 8 sessions” following the United Kingdom’s National Institute for Health and Care Excellence (NICE) guidelines for the psychotherapy of PTSD [31]; this also has the advantage of mirroring definitions used in previous WMHS research on effective treatment coverage for MDD [18].
We also defined a severity-specific variable for effective treatment coverage, which for mild and moderate PTSD required adequate pharmacotherapy and/or adequate psychotherapy, and for severe PTSD both adequate pharmacotherapy and adequate psychotherapy [26, 32]. These criteria are consistent with our previous work on depression. However, the evidence-base on combined treatment for PTSD is thin, and most PTSD guidelines do not recommend initiating treatment with combined pharmacotherapy and psychotherapy [33]. Nevertheless, there is a clinical rationale for considering combined treatment in some patients, and the combination of evidence-based pharmacotherapy and psychotherapy has been recommended when initial treatments fail [34].
The sample for analysis was respondents who met criteria for 12-month PTSD. Differences in within-household probabilities of selection and residual discrepancies between sample and population distributions were adjusted for through weights based on census demographic-geographic variables [21]. The Taylor series linearization method [35] implemented in SUDAAN software [36] was used to estimate standard errors to adjust for weighting and geographic clustering of data. Components of effective treatment coverage were stratified by country-income level.
As described in our previous work [30], bivariate logistic regression analyses were employed to explore significant associations between a broad set of potential predictors (gender, age, marital status, income, education, type of health insurance, private insurance (yes/no), any form of insurance (yes/no), employment status, severity, and survey year) and the outcome of interest, effective treatment coverage for PTSD. A multivariable logistic regression model was employed to predict effective treatment coverage including all the variables that had p < .01 in the bivariate analyses. Significance was established at p < 0.05, and we report the unadjusted p values as well as values adjusted for false discovery rates (FDR) resulting from multiple testing using the Benjamini-Hochberg procedure.
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Additionally, as detailed in previous articles in this series [18], for those bivariate models that were significant in predicting effective treatment coverage, we conducted exploratory analyses by decomposing this indicator to identify which components may drive coverage for specific subgroups. Thus, we investigated determinants of contact coverage among those with 12-month PTSD, and of the specific components of treatment (i.e., any pharmacotherapy, adequate pharmacotherapy, any psychotherapy, and adequate psychotherapy) among those with 12-month PTSD and contact coverage. Finally, we stratified the bivariate and multivariable analyses by country-income level.
Results
Effective treatment coverage
Twelve-month PTSD prevalence in trauma exposed individuals was 1.49% (S.E., 0.08) across countries. A total of 43.0% (S.E., 2.2) of these cases had contact coverage. Among these individuals with contact coverage (a) 32.7% (S.E., 1.9) received pharmacotherapy, but fewer received antidepressants (22.1% [S.E., 1.6]), and only 13.5% (S.E., 1.4) received adequate pharmacotherapy; (b) 19.9% (S.E., 1.5) received psychotherapy and slightly less (17.2% [S.E., 1.5]) received adequate psychotherapy; (c) 14.4% (S.E., 1.4) received effective treatment coverage (Table 3).
Table 3
Coverage for posttraumatic stress disorder by severity
Coverage
Severe n = 504
Mild/ Moderate n = 410
Any severity n = 914
Significance test
Numerator
Denominator
%
(SE)
%
(SE)
%
(SE)
F
(p-value)
Contact coveragea
People with 12-month PTSD
(n = 914)
58.1
(2.9)
32.7
(2.6)
43.0
(2.2)
43.31*
(<.001)
Any psychotropic medicationb,c
46.5
(2.7)
23.1
(2.3)
32.7
(1.9)
37.64*
(<.001)
Antidepressantsd
34.1
(2.5)
13.8
(1.7)
22.1
(1.6)
47.72*
(<.001)
Adequate medication controle
32.1
(2.6)
9.4
(1.5)
18.7
(1.5)
53.48*
(<.001)
Adequate pharmacotherapyf
23.0
(2.4)
7.0
(1.3)
13.5
(1.4)
35.74*
(<.001)
Any psychotherapyg
29.5
(2.5)
13.3
(1.6)
19.9
(1.5)
31.52*
(<.001)
Adequate psychotherapyh
28.0
(2.6)
9.7
(1.5)
17.2
(1.5)
47.56*
(<.001)
Effective coveragei
18.5
(2.2)
11.7
(1.7)
14.4
(1.4)
6.03*
(0.01)
Abbreviations: PTSD Posttraumatic stress disorder, SE Standard error
*Significant at the .05 level, two-sided test
aContact coverage required any 12-month contact with a specialist or general medical provider for a mental health condition
bRequires any 12-month healthcare/contact coverage too
cAny psychotropic required receiving any psychotropic and any 12-month healthcare
dAntidepressants required appropriate medication (antidepressant) and any 12-month healthcare
eAdequate medication control required at least four physician visits
fAdequate pharmacotherapy required taking an antidepressant with adequate medication control and adherence
gAny psychotherapy required having two or more visits to any specialty mental health provider among help seekers
hAdequate psychotherapy required at least 8 sessions from an adequate provider or still being in treatment after 2 visits
iEffective treatment coverage, for mild and moderate PTSD required adequate pharmacotherapy and/or adequate psychotherapy, and for severe PSTD both adequate pharmacotherapy and adequate psychotherapy
Stratification by country income-level (HIC vs LMIC) demonstrated that (a) contact coverage (50.6% vs 19.8%; (b) adequate pharmacotherapy (16.6% vs 4.1%); (c) adequate psychotherapy (21.3% vs 4.5%; and (d) effective treatment coverage (17.8% vs 4.1%) were all higher in HICs than in LMICs (Fig. 1).
Fig. 1
Treatment coverage for posttraumatic stress disorder (12-month PTSD). HICs (n = 694): High income countries; LMICs (n = 220): Low/ middle income countries. Contact coverage required any 12-month contact with a specialist or general medical provider for a mental health condition. Any psychotropic required receiving any psychotropic and any 12-month healthcare. Antidepressants required appropriate medication (antidepressant) and any 12-month healthcare. Adequate medication control required at least four physician visits. Adequate pharmacotherapy required taking an antidepressant with adequate medication control and adherence. Any psychotherapy required having two or more visits to any specialty mental health provider among help seekers. Adequate psychotherapy required at least 8 sessions from an adequate provider or still being in treatment after 2 visits. Effective treatment coverage, for mild and moderate PTSD required adequate pharmacotherapy and/or adequate psychotherapy, and for severe PSTD both adequate pharmacotherapy and adequate psychotherapy
×
Predictors of effective treatment coverage
In initial bivariate models, level of education, type of insurance, and severity of symptoms were associated with effective treatment coverage (Table 4). Those with low-average and average-high levels of education were less likely to receive effective treatment than those with high level of education. In general, those with any form of insurance are more likely to receive effective treatment coverage than those with no insurance. Having state funded coverage or subsidized insurance made it more likely to receive any modality of therapy and effective treatment, while those with insurance through employment or national social security were more likely to receive any pharmacotherapy, adequate pharmacotherapy, or effective treatment. Those with mild or moderate symptoms were less likely to receive any or adequate pharmacotherapy, or any or adequate psychotherapy, and those with mild symptoms were less likely to receive effective treatment. Stratification by country-income level showed similar findings in HICs (Supplemental Tables S1 and S2), while in LMICs the sample size did not allow for analyses by effective treatment and its components, analyses of contact coverage found that any form of insurance was particularly important in predicting contact coverage (Supplement Table S3).
Table 4
Bivariate predictors of effective coverage and its components among those with 12-Month posttraumatic stress disorder, in all countries (n = 914)a
Among those with 12-month PTSD (n = 914), received contact coverageb
Among those with 12-month PTSD (n = 914), received effective coverageg
Received any pharmacotherapy
Received adequate pharmacotherapyd
Received any psychotherapye
Received adequate psychotherapyf
OR
(95% CI)
F test
OR
(95% CI)
F test
OR
(95% CI)
F test
OR
(95% CI)
F test
OR
(95% CI)
F test
OR
(95% CI)
F test
FDRh
Level of education
Low
0.9
(0.6–1.5)
2.3@
1.1
(0.7–1.9)
5.3*
0.9
(0.5–1.7)
3.0*
0.6
(0.4–1.1)
1.7
0.6
(0.3–1.1)
1.5
0.7
(0.4–1.3)
2.3@
0.07
Low-Average
0.6
(0.4–1.1)
0.7
(0.4–1.1)
0.6
(0.3–1.1)
0.6*
(0.4–0.99)
0.6
(0.4–1.1)
0.5*
(0.3–0.9)
Average-High
0.5*
(0.3–0.9)
0.5*
(0.3–0.7)
0.5*
(0.3–0.8)
0.6
(0.4–1.04)
0.6
(0.4–1.3)
0.5*
(0.3–0.9)
High
REF
REF
REF
REF
REF
REF
Type of insurance
No insurance coverage
REF
REF
REF
REF
REF
REF
State funded coverage or subsidized insurance
3.9*
(2.2–6.9)
3.5*
(1.6–7.9)
3.5*
(1.5–8.3)
2.7*
(1.3–5.6)
3.6*
(1.5–8.6)
3.1*
(1.4–7.1)
Other
1.8*
(1.01–3.2)
1.8
(0.9–3.5)
1.4
(0.4–3.3)
1.5
(0.8–2.8)
1.8
(0.8–4.1)
1.6
(0.8–3.3)
Direct Private/Optional Insurance
1.9
(0.8–4.2)
6.7*
1.6
(0.6–4.3)
4.4*
1.7
(0.6–5.2)
3.8*
1.7
(0.7–4.1)
3.9*
1.8
(0.6–5.0)
3.1*
2.2
(0.8–6.1)
2.7*
0.06
Insurance through employment or national social security
5.9*
(1.7–20.2)
5.4*
(1.5–19.0)
8.3*
(1.7–41.5)
3.4
(0.95–11.9)
2.9
(0.7–11.6)
5.4*
(1.4–21.4)
Insurance
Any Insurance (Yes)
2.3*
(1.3–4.1)
8.5*
2.2*
(1.1–4.4)
4.8*
2.1
(0.9–4.7)
3.1@
1.8
(0.97–3.4)
3.5
2.2*
(1.01–4.9)
4.0*
2.1*
(1.02–4.5)
4.1*
0.06
Severity
Mild
0.2*
(0.1–0.3)
0.1*
(0.08–0.2)
0.1*
(0.04–0.3)
0.3*
(0.2–0.6)
0.2*
(0.08–0.3)
0.4*
(0.2–0.8)
Moderate
0.4*
(0.3–0.6)
29.7*
0.5*
(0.3–0.7)
24.9*
0.3*
(0.2–0.5)
18.0*
0.4*
(0.3–0.6)
15.9*
0.3*
(0.2–0.5)
25.0*
0.8
(0.5–1.2)
3.7*
0.06
Severe
REF
REF
REF
REF
REF
REF
Abbreviations: PTSD Posttraumatic stress disorder, OR Odds ratio, CI Confidence interval
*Significant at the .05 level, two-sided test @P < 0.1
aModels are bivariate with each demographic predictor in separate models, controlling for country dummies. The following variables were non-significant or P > 0.1: age, sex, marital status, income, employment status and survey year
bContact coverage required any 12-month contact with a specialist or general medical provider for a mental health condition
cAny psychotropic required receiving any psychotropic and any 12-month healthcare
Antidepressants required appropriate medication (antidepressant) and any 12-month healthcare
Adequate medication control required at least four physician visits
dAdequate pharmacotherapy required taking an antidepressant with adequate medication control and adherence
eAny psychotherapy required having two or more visits to any specialty mental health provider among help seekers
fAdequate psychotherapy required at least 8 sessions from an adequate provider or still being in treatment after 2 visits
gEffective treatment coverage, for mild and moderate PTSD required adequate pharmacotherapy and/or adequate psychotherapy, and for severe PSTD both adequate pharmacotherapy and adequate psychotherapy
hFDR: False discovery rate adjustment for multiple testing implementing the Benjamini-Hochberg method
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In the final multivariable model, after adjusting for the FDR, any form of insurance (OR = 2.31, 95% CI 1.17, 4.57) and mild symptom severity (OR = .35, 95% CI 53,1.08) remained significant predictors (Table 5). Stratification by country-income level showed similar findings in HICs (Supplement Table S2), while in LMICs although sample size again did not allow analyses by effective treatment and its components any form of insurance was again particularly important in predicting contact coverage (Supplement Table S3).
Table 5
Multivariable model of effective coverage among those with 12-Month posttraumatic stress disorder, in all countries (n = 914) a
Among those with 12-month PTSD (n = 914), received effective coverage
OR
(95% CI)
F test
FDRb
Level of education
Low-Average Education Y/N
0.76
(0.52–1.11)
2.02
0.157
Type of insurance
Any Insurance Y/N
2.31*
(1.17–4.57)
5.88*
0.025
Severity
Mild
0.35*
(0.18–0.70)
Moderate
0.76
(0.53–1.08)
5.10*
0.021
Severe
REF
Global F test for multivariate model
7.08*
Abbreviations: PTSD Posttraumatic stress disorder, O, Odds ratio, CI Confidence interval
*Significant at the .05 level, two-sided test
aModel is a multivariate model with all rows in the same model, controlling for country dummies
bFDR: False discovery rate adjustment for multiple testing implementing the Benhamini-Hochberg method
Discussion
Key findings from this analysis of WHO World Mental Health Surveys (WMHS) data were 1) that only 43.0.% of those with 12-month PTSD had contact coverage, with fewer receiving adequate pharmacotherapy (13.5%), adequate psychotherapy (17.2%), or effective treatment coverage (adequate severity specific use of pharmacotherapy and/or psychotherapy) (14.4%), and with all components of treatment coverage lower in LMICs than HICs, and 2) that lack of insurance and mild clinical symptoms were predictive of lower effective treatment coverage for PTSD.
The literature on treatment coverage of PTSD is relatively sparse. In veterans in the United States, studies have found that 23–40% of those who screened positive for a mental health issue received professional assistance [37], that 53% of those recently diagnosed with PTSD in primary care started treatment at that level [38], and that only 33% of veterans have received minimally adequate PTSD care [39]. In earlier work from the WMHS, of those with a 12-month anxiety disorder or PTSD, only 41.3% perceived a need for care, and only 27.6% received any treatment [10].
Several barriers to treatment of PTSD have previously been reported in the literature. These include both structural barriers such as lack of those providing evidence-based psychotherapy for PTSD [40], and attitudinal barriers such as ambivalence about treatment seeking [41]. In veterans in the US, those recently diagnosed with and treated at primary care level are more likely to receive pharmacotherapy [42]. In earlier work from the WMHS on barriers to care, low perceived need was the most common reason for not initiating treatment and was more common among moderate and mild than severe cases. Notably, attitudinal barriers dominated for mild-moderate cases, while structural barriers were more important for severe cases [13].
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The finding that patients with more severe symptoms are more likely to receive effective treatment coverage suggests that a more comprehensive treatment package is available for people who suffer severe PTSD, compared to those that suffer severe MDD [18]. While more severe PTSD symptoms may be associated with more disability, previous findings from WMHS have emphasized the graded relationship between PTSD severity and clinical outcomes [43]. Thus decisions about treating cases should be based on cost-effectiveness rather than severity [44]. There is growing evidence of the cost-effectiveness of interventions for individuals meeting diagnostic criteria for PTSD, although further such work is needed [4].
The most important social determinant of treatment coverage was the presence of insurance. Private insurance was also found to be a significant predictor in our previous work on effective treatment coverage for major depressive disorder, but in this case the difference is more salient: every form of insurance warrants increased coverage for PTSD when compared to no insurance [18]. A focus on the relevance of insurance for treatment coverage is timely given the current emphasis on universal health care coverage [14, 45].
Some limitations deserve emphasis. First, the data regarding service utilization and adherence are dependent on respondent recall. However, the focus here on 12-month treatment rather than lifetime prevalence minimizes recall bias. To compensate for potential bias we used a particularly stringent compliance threshold (taking the indicated dose at least 90% of the time) [27‐29]. With respect to the time-span covered by surveys, our models included dummy control variables for each survey, an approach that controls for survey year, so that findings are based on pooled within-survey results. Second, several aspects of the treatment provided, such as adherence to treatment manuals, may influence judgments of whether or not treatment coverage was effective. While a clinical trial allows assessment of such issues, it does not have the statistical power of an epidemiological approach. Third, our definitions of adequate treatment mirror our prior work on depression, but the evidence-base of randomized controlled trials of interventions for PTSD is smaller, with fewer approved pharmacotherapies, fewer evidence-based psychotherapies, and less evidence for the value of combined pharmacotherapy and psychotherapy [33]. Although our definitions of adequate treatment overlap in part with evidence-based guidelines for PTSD such as the NICE guideline their limitations deserve emphasis; for example, although such treatment guidelines for PTSD note the value of both pharmacotherapy and psychotherapy, they emphasize initiating treatment with either specific antidepressants or psychotherapies, rather than their combination.
In summary, these data emphasize that there is a clear need to improve pharmacotherapy and psychotherapy coverage for PTSD, particularly in those with mild symptoms, and especially in LMIC contexts. Previous work has emphasized the potential value of increasing human resources for mental health care and of increasing population mental health literacy in order to address structural and attitudinal barriers to accessing mental health services [14]. A key component of addressing such barriers is the provision of universal health care insurance for both physical and mental disorders.
Acknowledgments
WHO World Mental Health Survey Collaborators:
The WHO World Mental Health Survey collaborators are Sergio Aguilar-Gaxiola25, Ali Al-Hamzawi26, Jordi Alonso6, Yasmin A. Altwaijri27, Laura Helena Andrade7, Lukoye Atwoli28,29, Corina Benjet30, Guilherme Borges31, Evelyn J. Bromet32, Ronny Bruffaerts8, Brendan Bunting33, Jose Miguel Caldas-de-Almeida34, Graça Cardoso9, Stephanie Chardoul10, Somnath Chatterji35, Alfredo H. Cia36, Louisa Degenhardt37, Koen Demyttenaere38, Silvia Florescu12, Giovanni de Girolamo11, Oye Gureje13, Josep Maria Haro14; Meredith G. Harris5, Hristo Hinkov39, Chi-yi Hu40, Peter de Jonge41,42, Aimee Nasser Karam15, Elie G. Karam15,16, Georges Karam15, Norito Kawakami43, Ronald C. Kessler4, Andrzej Kiejna44, Viviane Kovess-Masfety17, Sing Lee18, Jean-Pierre Lepine45, John J. McGrath46,47,48, Maria Elena Medina-Mora19, Jacek Moskalewicz49, Fernando Navarro-Mateu20, Marina Piazza50,51, Jose Posada-Villa21, Kate M. Scott52, Tim Slade53, Juan Carlos Stagnaro22, Dan J. Stein1, Margreet ten Have23, Yolanda Torres54, Maria Carmen Viana55, Daniel V. Vigo3,24, Harvey Whiteford56, David R. Williams57, Bogdan Wojtyniak58.
25Center for Reducing Health Disparities, UC Davis Health System, Sacramento, California, USA.
26College of Medicine, University of Al-Qadisiya, Diwaniya governorate, Iraq.
27Epidemiology Section, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
28Department of Mental Health and Behavioural Sciences, Moi University School of Medicine, Eldoret, Kenya.
29Brain and Mind Institute and Medical College East Africa, the Aga Khan University, Nairobi, Kenya.
30Department of Epidemiologic and Psychosocial Research, National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico.
31National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico.
32Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York, USA.
33School of Psychology, Ulster University, Londonderry, United Kingdom.
34 Lisbon Institute of Global Mental Health and Chronic Diseases Research Center (CEDOC), NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal.
35Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland.
36Anxiety Disorders Research Center, Buenos Aires, Argentina.
37National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
38Department of Psychiatry, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
39National Center of Public Health and Analyses, Sofia, Bulgaria.
40Shenzhen Institute of Mental Health, Shenzhen Kangning Hospital, Shenzhen, China.
41Department of Developmental Psychology, University of Groningen, Groningen, The Netherlands.
42 Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, The Netherlands.
43Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
44Faculty of Applied Studies, University of Lower Silesia, Wroclaw, Poland.
45Hôpital Lariboisière-Fernand Widal, Assistance Publique Hôpitaux de Paris, Universités Paris Descartes-Paris Diderot, Paris, France.
46Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia.
47Queensland Brain Institute, The University of Queensland, St Lucia, Australia.
48National Centre for Register-based Research, Aarhus University, Aarhus, Denmark.
49Institute of Psychiatry and Neurology, Warsaw, Poland.
50Instituto Nacional de Salud, Lima, Peru.
51Universidad Cayetano Heredia, Lima, Peru.
52Department of Psychological Medicine, University of Otago, Dunedin, Otago, New Zealand.
53The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, Australia.
54Center for Excellence on Research in Mental Health, CES University, Medellin, Colombia.
55Department of Social Medicine, Postgraduate Program in Public Health, Federal University of Espírito Santo, Vitoria, Brazil.
56School of Public Health, University of Queensland, Herston, Australia.
57Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
58Centre of Monitoring and Analyses of Population Health, National Institute of Public Health-National Research Institute, Warsaw, Poland.
Declarations
Ethics approval and consent to participate
All methods were carried out in accordance with relevant guidelines and regulations. 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. Details of the ethics committees for the WMH surveys can be viewed at this link: http://www.hcp.med.harvard.edu/wmh/ftpdir/IRB_Ethics_approval_WMH.pdf. They are: Bioethics Committee, School of Medicine, University of Buenos Aires (Argentina); Ethics Committee of the Institute of Public Health (Federal Public Service Health, Food Chain Safety, and Environment) (Belgium); Research and Ethics Committee of the School of Medicine, University of São Paulo (Brazil, São Paulo metropolitan area); Ethics Committee for the FES Social Foundation (Colombia); Research Committee of the School of Medicine, and Ethics Committee CES University of Medellín (Colombia – Medellín); Committee of the CNIL - Commission Nationale Informatique et Libertés (France); Ethics Committee of the University of Leipzig (Germany); Italian National Institute of Health (Italy); University of Balamand Faculty of Medicine Institutional Review Board (Lebanon); Ethics committee in research of the National Institute of Psychiatry Ramon de la Fuente Muñiz (Mexico); Ethics Committee of the Netherlands Institute of Mental Health and Addiction (Netherlands); University of Ibadan/University College Hospital Joint Ethics Committee (Nigeria); Ethics Committee, Faculdade de Ciências Médicas, Universidade Nova de Lisboa (Portugal); Ethic Commission, Scientific Board of National Institute for Research and Development in Health (Romania); Ethical committee of Sant Joan de Deu Serveis de Salut Mental and Ethical Committee of Institut Municipal d’Investigació Mèdica (Spain); Clinical Research Ethical Committee of Hospital Universitario Virgen de la Arrixaca (Murcia, Spain) (Spain - Murcia); Human Subjects Committees of the Institute for Social Research at the University of Michigan and of Harvard Medical School (United States).
Consent for publication
Not applicable.
Competing interests
MGH reports consulting fees from RAND Corporation outside the submitted work.
In the past 3 years, RCK was a consultant for Cambridge Health Alliance, Canandaigua VA Medical Center, Holmusk, Partners Healthcare, Inc., RallyPoint Networks, Inc., and Sage Therapeutics. He has stock options in Cerebral Inc., Mirah, PYM, and Roga Sciences.
FN-M reports non-financial support from Otsuka outside the submitted work.
DJS has received honoraria from Discovery Vitality, Johnson & John, Kanna, L’Oreal, Lundbeck, Orion, Sanofi, Servier, Takeda, and Vistagen.
The remaining authors declare that they have no competing interests.
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Determinants of effective treatment coverage for posttraumatic stress disorder: findings from the World Mental Health Surveys
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Dan J. Stein Alan E. Kazdin Richard J. Munthali Irving Hwang Meredith G. Harris Jordi Alonso Laura Helena Andrade Ronny Bruffaerts Graça Cardoso Stephanie Chardoul Giovanni de Girolamo Silvia Florescu Oye Gureje Josep Maria Haro Aimee N. Karam Elie G. Karam Viviane Kovess-Masfety Sing Lee Maria Elena Medina-Mora Fernando Navarro-Mateu José Posada-Villa Juan Carlos Stagnaro Margreet ten Have Nancy A. Sampson Ronald C. Kessler Daniel V. Vigo on behalf of the WHO World Mental Health Survey Collaborators
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