Patterns, predictors, and patient-reported reasons for antidepressant discontinuation in the WHO World Mental Health Surveys.

BACKGROUND: Despite their documented efficacy, substantial proportions of patients discontinue antidepressant medication (ADM) without a doctor's recommendation. The current report integrates data on patient-reported reasons into an investigation of patterns and predictors of ADM discontinuation. METHODS: Face-to-face interviews with community samples from 13 countries (n = 30 697) in the World Mental Health (WMH) Surveys included n = 1890 respondents who used ADMs within the past 12 months. RESULTS: 10.9% of 12-month ADM users reported discontinuation-based on recommendation of the prescriber while 15.7% discontinued in the absence of prescriber recommendation. The main patient-reported reason for discontinuation was feeling better (46.6%), which was reported by a higher proportion of patients who discontinued within the first 2 weeks of treatment than later. Perceived ineffectiveness (18.5%), predisposing factors (e.g. fear of dependence) (20.0%), and enabling factors (e.g. inability to afford treatment cost) (5.0%) were much less commonly reported reasons. Discontinuation in the absence of prescriber recommendation was associated with low country income level, being employed, and having above average personal income. Age, prior history of psychotropic medication use, and being prescribed treatment from a psychiatrist rather than from a general medical practitioner, in comparison, were associated with a lower probability of this type of discontinuation. However, these predictors varied substantially depending on patient-reported reasons for discontinuation. CONCLUSION: Dropping out early is not necessarily negative with almost half of individuals noting they felt better. The study underscores the diverse reasons given for dropping out and the need to evaluate how and whether dropping out influences short- or long-term functioning.

Antidepressant use in low- middle- and high-income countries: a World Mental Health Surveys report.

BACKGROUND: The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries. METHODS: Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents. RESULTS: 3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2-4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness. CONCLUSION: ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.

Determinants of effective treatment coverage for posttraumatic stress disorder: findings from the World Mental Health Surveys.

BACKGROUND: 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.

Drawing causal inferences from randomized controlled trials in psychotherapy research.

OBJECTIVE: Randomized control trials (RCTs) have played a critical role in psychotherapy research. This article discusses RCTs in the context of the criteria for drawing causal inferences in psychotherapy and intervention research more generally. The article also highlights underused variations of RCTs and how they not only establish causal relations but also address critical questions that can improve our intervention portfolio and patient care. CONCLUSION: Random assignment is discussed in terms of what it can and cannot do in relation to drawing conclusions about the effects of interventions. Finally, RCTs are examined in the context of multiple questions that can guide therapy research, improve patient care, and develop treatments that reach people in need of psychological services.

Perceived helpfulness of treatment for social anxiety disorder: findings from the WHO World Mental Health Surveys.

PURPOSE: To investigate the prevalence and predictors of perceived helpfulness of treatment in persons with a history of DSM-IV social anxiety disorder (SAD), using a worldwide population-based sample. METHODS: The World Health Organization World Mental Health Surveys is a coordinated series of community epidemiological surveys of non-institutionalized adults; 27 surveys in 24 countries (16 in high-income; 11 in low/middle-income countries; N = 117,856) included people with a lifetime history of treated SAD. RESULTS: In respondents with lifetime SAD, approximately one in five ever obtained treatment. Among these (n = 1322), cumulative probability of receiving treatment they regarded as helpful after seeing up to seven professionals was 92.2%. However, only 30.2% persisted this long, resulting in 65.1% ever receiving treatment perceived as helpful. Perceiving treatment as helpful was more common in female respondents, those currently married, more highly educated, and treated in non-formal health-care settings. Persistence in seeking treatment for SAD was higher among those with shorter delays in seeking treatment, in those receiving medication from a mental health specialist, and those with more than two lifetime anxiety disorders. CONCLUSIONS: The vast majority of individuals with SAD do not receive any treatment. Among those who do, the probability that people treated for SAD obtain treatment they consider helpful increases considerably if they persisted in help-seeking after earlier unhelpful treatments.

Perceived helpfulness of bipolar disorder treatment: Findings from the World Health Organization World Mental Health Surveys.

OBJECTIVES: To examine patterns and predictors of perceived treatment helpfulness for mania/hypomania and associated depression in the WHO World Mental Health Surveys. METHODS: Face-to-face interviews with community samples across 15 countries found n = 2,178 who received lifetime mania/hypomania treatment and n = 624 with lifetime mania/hypomania who received lifetime major depression treatment. These respondents were asked whether treatment was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Patterns and predictors of treatment helpfulness were examined separately for mania/hypomania and depression. RESULTS: 63.1% (mania/hypomania) and 65.1% (depression) of patients reported ever receiving helpful treatment. However, only 24.5-22.5% were helped by the first professional seen, which means that the others needed to persist in help seeking after initial unhelpful treatments in order to find helpful treatment. Projections find only 22.9% (mania/hypomania) and 43.3% (depression) would persist through a series of unhelpful treatments but that the proportion helped would increase substantially if persistence increased. Few patient-level significant predictors of helpful treatment emerged and none consistently either across the two components (i.e., provider-level helpfulness and persistence after earlier unhelpful treatment) or for both mania/hypomania and depression. Although prevalence of treatment was higher in high-income than low/middle-income countries, proportional helpfulness among treated cases was nearly identical in the two groups of countries. CONCLUSIONS: Probability of patients with mania/hypomania and associated depression obtaining helpful treatment might increase substantially if persistence in help-seeking increased after initially unhelpful treatments, although this could require seeing numerous additional treatment providers. In addition to investigating reasons for initial treatments not being helpful, messages reinforcing the importance of persistence should be emphasized to patients.

Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report.

BACKGROUND: Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. METHODS: Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. RESULTS: The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness. CONCLUSIONS: The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.

The Influence of Interactions with Dogs on Affect, Anxiety, and Arousal in Children.

Interactions with animals represent a promising way to reduce the burden of childhood mental illness on a large scale. However, the specific effects of child-animal interactions are not yet well-established. This study provides a carefully controlled demonstration that unstructured interactions with dogs can improve clinically relevant symptoms in children. Seventy-eight children (55.1% female, 44.9% male) ages 10 to 13 (M = 12.01, SD = 1.13) completed the Trier Social Stress Test for Children, followed by (a) interaction with a dog, (b) a tactile-stimulation control condition, or (c) a waiting control condition. The Positive and Negative Affect Schedule for Children, Short Form and the State/Trait Anxiety Inventory for Children were completed at baseline and posttest, and salivary cortisol was assessed at 5 time points. Adjusting for baseline scores, participants in the experimental condition showed higher scores on the Positive Affect scale than participants in both control conditions and lower scores on the State/Trait Anxiety Inventory for Children than participants in the waiting control condition at posttest. Negative affect was not assessed reliably, and we detected no effect of the interactions on salivary cortisol, as measured by area under the curve with respect to ground. Brief, unstructured interactions with dogs boosted children's positive emotions and reduced anxiety. Additional research is needed to further clarify which features of the interactions produce these benefits and the extent to which interactions with animals offer benefits that exceed the effects of other common coping strategies, activities, and interventions.

Annual Research Review: Expanding mental health services through novel models of intervention delivery.

Currently, in the United States and worldwide, the vast majority of children and adolescents in need of mental health services receive no treatment. Although there are many barriers, a key barrier is the dominant model of delivering psychosocial interventions. That model includes one-to-one, in-person treatment, with a trained mental health professional, provided in clinical setting (e.g., clinic, private practice office, health-care facility). That model greatly limits the scale and reach of psychosocial interventions. The article discusses many novel models of delivering interventions that permit scaling treatment to encompass children and adolescents who are not likely to receive services. Special attention is accorded the use of social media, socially assistive robots, and social networks that not only convey the ability to scale interventions but also encompass interventions that depart from the usual forms of intervention that currently dominate psychosocial treatment research.

Perceptions of animal-assisted interventions: The influence of attitudes toward companion animals.

OBJECTIVE: We tested whether people are prone toward positive perceptions of Animal-Assisted Interventions (AAIs). We additionally evaluated whether this effect is stronger for people who have positive attitudes toward companion animals. METHOD: We presented 210 participants with fictitious news reports, each describing a study of an AAI or a control intervention. Participants rated the news reports on their credibility, acceptability, and general appeal and completed a measure of attitudes toward companion animals. RESULTS: Individuals with positive attitudes toward companion animals evaluated AAIs as more credible, acceptable, and positive than did individuals with negative attitudes toward companion animals. There was no difference in how people with positive and negative attitudes toward companion animals evaluated control treatments. CONCLUSION: We found that individuals with positive attitudes toward companion animals perceived AAIs as more credible, acceptable, and positive, relative to individuals with more negative attitudes toward companion animals.

Implementation and evaluation of treatments for children and adolescents with conduct problems: Findings, challenges, and future directions.

OBJECTIVE: The intervention work of our clinical-research team has focused on the treatment of children and young adolescents referred for Conduct Disorder or Oppositional Defiant Disorder. METHOD: We have evaluated two interventions: parent management training (PMT) and cognitive problem-solving skills training in several randomized controlled clinical trials. RESULTS: Our findings have indicated the treatments, alone or in combination, produce reliable and significant reductions in oppositional, aggressive, and antisocial behaviour and increases in prosocial behaviour among children. Parent dysfunction (depression, multiple symptom domains) and stress decline and family relations improve as well. Apart from outcome studies, we have studied the therapeutic alliance, factors that influence dropping out and retaining cases, and variations of treatment delivery (e.g., computer based, reduced therapist contact). CONCLUSIONS: The article considers challenges in conducting controlled trials in clinic settings (e.g., recruiting cases, maintaining treatment integrity, securing funding) and activities related to implementation that are not easily covered within the confines of research articles. The article ends with a discussion of one of the treatments (PMT) and the broad role it can play in treatment, prevention, and help with many parenting challenges of everyday life.

Addressing critical gaps in the treatment of eating disorders.

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.

Clinical dysfunction and psychosocial interventions: the interplay of research, methods, and conceptualization of challenges.

I describe the development and course of my research in studying clinical dysfunction among children, adolescents, and adults. This is an autobiographical account that highlights programs of research, career moves, and experiences along the way that were particularly influential. Research on specific topics and the methods to study them were inherently fascinating but invariably led me to broader issues well beyond what I was studying. The research alerted me to how and why current methods, assumptions, and research practices might be constraining and perhaps slightly misguided. My research and specific findings in a given area were not necessarily part of any particular breakthrough but rather helped me see how more, different, and better work was needed. Collaborations with a diverse set of colleagues and models from other disciplines than psychology helped me conceptualize the goals of research on a given topic (e.g., developing evidence-based treatments, reducing the burden of mental illness, promoting a sustainable environment to mitigate climate change) and propose a shift from current practices as a means to obtain them.

Interventions in everyday life to improve mental health and reduce symptoms of psychiatric disorders.

The high prevalence rates of mental disorders worldwide and the paucity of services constitute a mental health crisis. The vast majority of people in low-, middle-, and high-income countries do not receive any intervention for their symptoms of mental disorders, despite enormous advances in developing evidence-based psychosocial treatments and medications. The article proposes greater utilization of interventions in everyday life as an addition to the more traditional and commonly used mental-health interventions. The article delineates criteria to help identify what such interventions ought to include to permit accessibility, scalability, and reach to special populations. Physical activity, contact with nature, and yoga are examples to illustrate the class of everyday interventions that have evidence attesting to their impact on mental health and symptoms of psychopathology. The challenge is to integrate such interventions in mental health practices to better promote these at the population level and to monitor the impact. Many components of what is needed are in place but are not coordinated in an effective way to have widespread impact on mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Where to begin to have impact on the treatment gap: Reply to Coifman and Gunstad (2024).

Coifman and Gunstad (2024) raise cogent points about childhood and adolescence as a place to begin to help close the mental health treatment gap, note the potential of applications (apps) as a modality of intervention given the pervasiveness of smartphones, and highlight a large-scale intervention study to convey that treatments can be scaled in outcome research. I expand the range of interventions we might consider, pose a best-buy approach to decide how and where to begin to address the treatment gap, and underscore that mental health problems in children, adolescents, and adults are on the rise. We still have no evidence that we can close the treatment gap and that to do so will require a marriage of multiple disciplines, interventions, and agencies to effect change. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The influence of interactions with pet dogs on psychological distress.

Many people, including nearly half of American households, own a pet dog. Previous work has found that therapy dog interactions reduce distress, but little work to date has empirically established the mood-enhancing effects of interaction with one's own pet dog. In this study, dog owners (N = 73; 86.3% female, 13.7% male; age 25-77 years) underwent a stress-inducing task followed by random assignment to either (a) interacting with their dog (n = 24), (b) an expectancy control (n = 25; "stress-reducing" coloring books), or (c) a waiting control (n = 24). We compared the effects of each condition on affect and state anxiety. Participants assigned to the dog interaction showed greater increases in positive affect, as well as greater reductions in anxiety compared to both expectancy and waiting controls (ds > 0.72, ps < .018). No significant reductions in negative affect were detected. Second, we found that self-reported experiences with animals, attitudes toward animals, or bondedness with their dog did not differentially predict the condition's impact on the owner's mood. Finally, we coded participants' degree of engagement (e.g., time spent playing) with the dog and found that higher engagement predicted reduced negative affect. Overall, interacting with one's own pet dog reduced owners' distress. Such interactions, which occur commonly in daily life, may have the potential to alleviate distress at a large scale. Precisely how this works and for whom it is especially well suited remain intriguing open questions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Comparative effectiveness of remote digital gamified and group CBT skills training interventions for anxiety and depression among college students: Results of a three-arm randomised controlled trial.

Digital interventions can enhance access to healthcare in under-resourced settings. However, guided digital interventions may be costly for low- and middle-income countries, despite their effectiveness. In this randomised control trial, we evaluated the effectiveness of two digital interventions designed to address this issue: (1) a Cognitive Behavioral Therapy Skills Training (CST) intervention that increased scalability by using remote online group administration; and (2) the SuperBetter gamified self-guided CBT skills training app, which uses other participants rather than paid staff as guides. The study was implemented among anxious and/or depressed South African undergraduates (n = 371) randomised with equal allocation to Remote Group CST, SuperBetter, or a MoodFlow mood monitoring control. Symptoms were assessed with the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9). Intention-to-treat analysis found effect sizes at the high end of prior digital intervention trials, including significantly higher adjusted risk differences (ARD; primary outcome) in joint anxiety/depression remission at 3-months and 6-months for Remote Group CST (ARD = 23.3-18.9%, p = 0.001-0.035) and SuperBetter (ARD = 12.7-22.2%, p = 0.047-0.006) than MoodFlow and mean combined PHQ-9/GAD-7 scores (secondary outcome) significantly lower for Remote Group CST and SuperBetter than MoodFlow. These results illustrate how innovative delivery methods can increase the scalability of standard one-on-one guided digital interventions. PREREGISTRATION INTERNATIONAL STANDARD RANDOMISED CONTROLLED TRIAL NUMBER (ISRTCN) SUBMISSION #: 47,089,643.

Population mental health science: Guiding principles and initial agenda.

A recent American Psychological Association Summit provided an urgent call to transform psychological science and practice away from a solely individual-level focus to become accountable for population-level impact on health and mental health. A population focus ensures the mental health of all children, adolescents, and adults and the elimination of inequities across groups. Science must guide three components of this transformation. First, effective individual-level interventions must be scaled up to the population level using principles from implementation science, investing in novel intervention delivery systems (e.g., online, mobile application, text, interactive voice response, and machine learning-based), harnessing the strength of diverse providers, and forging culturally informed adaptations. Second, policy-driven community-level interventions must be innovated and tested, such as public efforts to promote physical activity, public policies to support families in early life, and regulation of corporal punishment in schools. Third, transformation is needed to create a new system of universal primary care for mental health, based on models such as Family Connects, Triple P, PROmoting School-community-university Partnerships to Enhance Resilience, Communities That Care, and the Early Childhood Collaborative of the Pittsburgh Study. This new system must incorporate valid measurement, universal screening, and a community-based infrastructure for service delivery. Addressing tasks ahead, including scientific creativity and discovery, rigorous evaluation, and community accountability, will lead to a comprehensive strategic plan to shape the emergent field of public mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Factors associated with satisfaction and perceived helpfulness of mental healthcare: a World Mental Health Surveys report.

BACKGROUND: Mental health service providers are increasingly interested in patient perspectives. We examined rates and predictors of patient-reported satisfaction and perceived helpfulness in a cross-national general population survey of adults with 12-month DSM-IV disorders who saw a provider for help with their mental health. METHODS: Data were obtained from epidemiological surveys in the World Mental Health Survey Initiative. Respondents were asked about satisfaction with treatments received from up to 11 different types of providers (very satisfied, satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, very dissatisfied) and helpfulness of the provider (a lot, some, a little, not at all). We modelled predictors of satisfaction and helpfulness using a dataset of patient-provider observations (n = 5,248). RESULTS: Most treatment was provided by general medical providers (37.4%), psychiatrists (18.4%) and psychologists (12.7%). Most patients were satisfied or very satisfied (65.9-87.5%, across provider) and helped a lot or some (64.4-90.3%). Spiritual advisors and healers were most often rated satisfactory and helpful. Social workers in human services settings were rated lowest on both dimensions. Patients also reported comparatively low satisfaction with general medical doctors and psychiatrists/psychologists and found general medical doctors less helpful than other providers. Men and students reported lower levels of satisfaction than women and nonstudents. Respondents with high education reported higher satisfaction and helpfulness than those with lower education. Type of mental disorder was unrelated to satisfaction but in some cases (depression, bipolar spectrum disorder, social phobia) was associated with low perceived helpfulness. Insurance was unrelated to either satisfaction or perceived helpfulness but in some cases was associated with elevated perceived helpfulness for a given level of satisfaction. CONCLUSIONS: Satisfaction with and perceived helpfulness of treatment varied as a function of type of provider, service setting, mental status, and socio-demographic variables. Invariably, caution is needed in combining data from multiple countries where there are cultural and service delivery variations. Even so, our findings underscore the utility of patient perspectives in treatment evaluation and may also be relevant in efforts to match patients to treatments.

Addressing the treatment gap: Expanding the scalability and reach of treatment.

What is the public health significance of this article? The focus is on the treatment gap, namely, the large discrepancy between the prevalence of mental disorders and the proportion of individuals who receive care. The vast majority of individuals in need of services receive no care at all. This article underscores the importance of developing treatments that can be scaled as well as reach those individuals least likely to receive services. Novel interventions and models of delivery are proposed to redirect intervention research and narrow the treatment gap. (PsycInfo Database Record (c) 2023 APA, all rights reserved).