Despite mental and substance use disorders having some of the most cost-effective interventions, they remain among the most disabling and economically impactful noncommunicable disorders across the world. To help understand patterns of care and treatment for those living with mental and substance use disorders, Advancing Health’s Dr. Daniel Vigo, Chair of the Services and Policy Workgroup, World Mental Health Surveys Initiative at the World Health Organization and Harvard Medical School, led a study conducting and examining World Mental Health surveys. The goal of this project was to identify the proportion of people with common mental and substance use disorders who received effective and adequate treatment consistent with international guidelines.
Published in JAMA Psychiatry, the analysis found that of over 56,000 respondents from 21 countries, only 6.9 per cent were receiving effective treatment consistent with international guidelines.
“This survey found that a very low proportion of people in need of treatment for mental and substance use disorders are getting effective treatment,” said Dr. Vigo. The study team includes researchers from 21 countries including South Africa, Australia, Brazil, and the United States.
Recognizing perceived need before addressing access
One of the most striking metrics measured in this survey was the perceived need to receive care. This information was collected by a combination of questions and survey design. For example, individuals who received treatment were asked about whether or not it was their choice to seek care, and those who indicated they felt pressured into it by loved ones were subsequently identified as participants who had no perceived need of care.
On the surface, availability of providers can seem like the main driver of whether or not individuals receive care for their mental and substance use disorders, but Dr. Vigo highlights that this intuition was not borne out in the results. “This study shows that, as high as 40 per cent of people who needed care did not seek it because they did not think that they needed it. Even in an ideal scenario where there are enough practitioners, these individuals would be lost to treatment despite having a mental or substance use disorder,” he explained.
However, the importance of care availability should not be minimized. While not involved in this particular research, Dr. Angela Russolillo, Advancing Health’s Program Head of Psychiatry, highlights that people with mental health or substance use concerns often face many barriers in accessing care.
“Access to care is impacted by several factors, including limited availability of services, and currently we are in a human resource crisis with regard to mental health and substance use providers,” said Dr. Russolillo. “Additionally, within Canada, psychologist or counselling support is only covered through private insurance, not within the provincial healthcare plans, which is an additional barrier to care.”
Furthermore, Dr. Vigo’s study found that among the participants who were able to receive care, less than half were receiving adequate or effective treatment in accordance with international guidelines. This indicates a major shortcoming in the quality of care people receive for mental and substance use disorders.
Factors that determine care
Both individual- and country-level predictors were evaluated in this study. At the individual level, one of the stand-out predictors of whether or not study participants are receiving effective care was their education level. Interestingly, while it is typically closely related to income, education was significant in determining whether participants received effective care while income level was not. Another parameter of note was whether a participant had insurance. In the countries surveyed, both public and private insurance were similar in how they improved the likelihood of receiving effective care.
“Public insurance often covers the first line of care — general practitioners — which for more severe mental and substance use disorders, such as opioid use disorder or bipolar disorder, leads to more specialized, covered care,” said Dr. Vigo. “But for people with mild or moderate needs, high-quality mental health care is often not covered. This leads to the nearly exclusive prioritization of the ones suffering the most, which is not very strategic in that it does not value prevention of those severe states.” Ideally, when it comes to fund allocation a balance should be sought to keep providing effective care to those most in need, while also improving the package of services covered for people with moderate needs.
At a country level, effective treatment was significantly and positively associated with country-level health resources: the number of non-psychiatrist physicians and proportional health spending were significant predictors for receiving effective care.
“Non-psychiatrist availability as a predictor of whether or not a patient received effective care for a mental and/or substance use disorder is a really important system-level finding,” said Dr. Russolillo. “We need to consider new models of care delivery, and investing more into educating general practitioners regarding mental and substance use disorders could have a significant impact on improving care overall, especially because we currently cannot produce enough specialists to meet the demand.”
Changes since COVID
Data from this survey were collected from 2001 to 2019, prior to the COVID-19 pandemic. Since then, demand for mental health care services has continued to grow.
When asked about what has changed since this survey was conducted, Dr. Vigo shared a couple of important points.
“There is the generalization of telemedicine, which has enormous potential for mental health and substance use, both in terms of increasing accessibility and the availability of specialists,” he said. “However, these were implemented at such a pace that, while it impacted access to care, it did not necessarily improve quality of care.”
Dr. Vigo also indicated that there used to be much less consensus when it came to how important mental health and substance use was, both at an individual level and its impact on population health, as well as its impact on economies. Since the pandemic, mental health is increasingly being recognized as a core part of well-being.
The pandemic also had negative impacts on mental health care, with one of the most noteworthy changes being the toll on both the physical and mental health of health care providers within the mental and substance use disorder space.
“One of the biggest challenges health care providers have faced is burnout, stress and fatigue, with no signs of slowing down since the demand for care is so high and resources are so low,” said Dr. Russolillo.
There is still much work to be done to improve effective treatment of mental and substance use disorders, and it starts with first recognizing that care is needed.
