Treatment coverage for major depressive disorder still wanting in poorer countries

Treatment coverage for major depressive disorder (MDD) remains low across the globe, especially in low- and lower middle-income countries, a study has found. However, many patients still fail to receive adequate care consistent with practice guidelines even in high-income countries.

“Ultimately, our findings emphasize the need for governments and policy makers to reconsider the availability of appropriate care for MDD and facilitators of treatment as they respond to the large burden imposed by this disorder,” the researchers said.

Using the databases of PubMed and Embase, the researchers performed a systematic review to identify relevant studies that provided data on the treatment rates for MDD between 1 January 2000 and 26 November 2021.

Studies were eligible if they made use of population-based surveys that represented communities, countries, or regions under inquiry and if they employed established diagnostic criteria to identify cases of MDD. Sample and methodological characteristics were extracted from selected studies.

The researchers modelled treatment rates using a Bayesian meta-regression approach and adjusted these for select covariates (eg, age, sex, treatment type, location, and choice of MDD assessment tool) quantifying heterogeneity in the data.

Overall, 149 studies met the eligibility criteria. Treatment coverage for health service use ranged from 51 percent (95 percent uncertainty interval [UI], 20‒82) in high-income countries to 20 percent (95 percent UI, 1‒53) in low- and lower middle-income countries. [PLoS Med 2022;19:e1003901]

For mental health service use, treatment coverage was 33 percent (95 percent UI, 8‒66) in high-income countries and 8 percent (95 percent UI, <1‒36) in low- and lower middle-income countries. Of note, minimally adequate treatment (MAT) rates ranged from 23 percent (95 percent UI, 2‒55) to 3 percent (95 percent UI, <1‒25) in low- and lower middle-income countries, respectively.

Access to mental healthcare

“[E]ven in high-income countries where treatment rates are comparatively higher, the majority of individuals receiving care for MDD failed to receive a level of care that is consistent with practice guideline recommendations,” the researchers said. “Only a small minority of individuals with MDD accessed treatment in the specialized mental healthcare system or received MAT.”

Additionally, many countries included in the review lacked mental health policies, legislation, or resources to conduct their mental health programs and services. [Lancet 2013;381:1970-1971; www.who int/mental_health/mindbank/en]

“However, simply access alone is not enough. The proportion of people who receive sufficient care once they enter treatment is still difficult to estimate and is unclear from the current literature,” the researchers said. “Therefore, it is important to consider not simply the presence of services, but what behavioural or environmental drivers impact contact with and adherence to treatment.”

Furthermore, treatment gaps for MDD must also consider disparities in psychosocial and physical healthcare. Psychosocial interventions have been found effective in reducing symptoms, while physical healthcare is necessary considering the high and often untreated physical comorbidity and premature mortality associated with MDD and other mental disorders. [World Psychiatry 2017;16:30-40]

The current systematic review and meta-analysis was limited by the lack of sufficient data from low- and lower middle-income countries, which prevented more detailed treatment rate estimates.