Abstract
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, 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 1 in 5 ever obtained treatment. Among these (n=1,322), cumulative probability of receiving treatment they regarded as helpful after seeing up to 7 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 healthcare 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 2 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.
Keywords: PERCEIVED HELPFULNESS, TREATMENT, SOCIAL ANXIETY DISORDER
INTRODUCTION
Social anxiety disorder (SAD) is one of the most prevalent mental disorders [1]. Epidemiological surveys estimate the 12-month and lifetime prevalence of SAD in the 0.6-8.0% (median 4.5%) and 2.8-13.0% (median 7.9%), respectively [2–4]. SAD has an early age-of-onset, usually between ages 13 and 15, and is often chronic. Moreover, more than 90% of individuals with the disorder report impairments such dropping out of school, reduced productivity at work, reduced socioeconomic status, and quality of life [1,5,6]. Despite the marked impairment, few people receive treatment [7], partly due to the core of the clinical condition itself: the fear of social situations and interactions make persons with SAD extremely hesitant to consult a health care professional. Among those who make it to treatment, psychological treatments or pharmacotherapy have been evaluated, either alone (for instance one psychological treatment against another) and in combination (for instance psychotherapy combined with pharmacotherapy) [8–10]. Typically, about only 34 – 65% respond to treatment. Moreover, remission rates can be high and up to approximately 35 percent [11,1].
Most studies on treatment effectiveness use self- and clinician-rated measures and focus on symptom changes. These measures are essential and form the core assessments of randomized controlled trials. Interestingly, improvements in such standardized measures evaluated changes in an individual outcome (such as symptom reduction) or accumulated into other indices (e.g., effect size, statistically significant changes) but, most importantly, they do not necessarily reflect the impact of interventions in everyday life nor on the patients views of whether the treatments are helpful and make any palpable difference [12,13]. Whether patients view treatment as making a difference or being helpful is rarely evaluated [14,15]. However, within a contemporary value-based framework in treating mental disorders [16], patient views of helpfulness provide a crucial additional source of information and may have critical implications for services that are provided [17].
Helpfulness is not merely a matter of the assessment after a given treatment. A longer term perspective is needed because many individuals traverse multiple treatments and seek different treatments over time. In this study, we focused on patient views of helpfulness over an extended or longer-term treatment course and also focus on the question on the association between the evaluation of helpfulness and continuing the pursue of treatment. An evaluation of this pathway requires information about the sequence of contacts of patients with health professionals following the onset of disorder. Against this, the probability of a patient ever receiving helpful treatment will be the product of two components: the probability of a given treatment provider being perceived as helpful and the probability the patient will persist in help-seeking after receiving unhelpful treatment [18]. Such decomposition into two components of the treatment pathway is important because these two components could have different determinants. In addition, they may vary across mental health sectors, reflecting elements such as availability of services and barriers to access. Obtaining this level of information is vital for the knowledge on and understanding of how individuals progress through a clinical treatment pathway; and is an important first step for future improvement efforts in the treatment of SAD.
Perceived helpfulness is not likely to be only a function of the type of treatment people may receive. Other domains may contribute to or indeed explain whether patients consider treatment as effective. Prior research has not considered factors that might well contribute to patient perceptions. To that end, we evaluated multiple variables within four domains. Each of these have been (in part) shown to be associated with perceived helpfulness for mental disorders, but where so far not considered together with regard to the study of perceived helpfulness for SAD. We included type and characteristics of treatment (like type of treatment, treatment provider) because prior study showed that, for instance for depression, perceived helpfulness is higher when persons receive treatment from mental health specialists [18]. In addition, we included current and past mental disorders (e.g., age of onset, comorbid disorders) as prior study suggested that treatment experience may vary upon history of prior treatment [19]. Lastly, childhood adversity (e.g., history physical abuse, sexual abuse, neglect, parental mental disorder, parental substance use disorder, parental criminal behavior, or family violence) were also included. We included these because childhood adversity has been repeatedly shown to be a risk factor for a broad range of mental and physical disorders, cognitive, behavioural, and social disability over the lifespan and moreover shows a “dose” response relation in relation to these risks [20].
The World Health Organization (WHO) World Mental Health (WMH) surveys were designed, among other objectives, to address perceived helpfulness of treatment. These general population-based surveys use structured psychiatric interviews, to measure the prevalence of SAD and information on respondents’ evaluation of treatment for this condition. The present study examined (a) the prevalence and predictors of perceived helpfulness of treatment, (b) two components related to perceived helpfulness of treatment (i.e., the probability of a given treatment provider being perceived as helpful; and the probability the patient will persist in help-seeking after receiving unhelpful treatment) using cross-national, representative community samples of individuals with a lifetime history of SAD treatment, and (c) variations of the above across high and low/middle-income countries worldwide.
METHODS
Sample
The WHO WMH surveys are a coordinated set of community epidemiological surveys administered to probability samples of the non-institutionalized household population in countries throughout the world (https://www.hcp.med.harvard.edu/wmh/). Data for the current report came from 27 WMH surveys carried out in 24 countries - 16 surveys in countries classified by the World Bank as high-income (Argentina; Australia; Belgium; France; Germany; Italy; Japan; the Netherlands; New Zealand; Northern Ireland; Poland; Portugal; Saudi Arabia; Spain; Murcia, Spain; and the United States) and 11 surveys in countries classified as low/middle-income (Sao Paulo Brazil; Bulgaria [separate surveys carried out in 2002 and 2016]; Colombia; Medellin, Colombia; Iraq; Lebanon; Mexico; Peru; Shenzhen in the People’s Republic of China [PRC]; and Romania). All surveys were based on nationally representative household samples, whereas 4 were representative of selected Metropolitan Areas (Sao Paolo, Brazil; Medellin, Colombia; Japan; Shenzhen, PRC), 1 of selected regions (Murcia, Spain), and 4 of all urbanized areas (Argentina; Colombia; Mexico; Peru). The field dates ranged from 2001 to 2017. Response rates ranged from 45.9% (France) to 97.2% (Medellin) and averaged 67.8% across surveys (see Appendix Table 1).
The interview schedule was developed in English and translated into other languages using a standardized WHO translation, team translation, and harmonization protocol. Interviews were administered face-to-face in respondents’ homes after obtaining informed consent using procedures approved by local Institutional Review Boards. The study is performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Interviews were in two parts. Part I was administered to all respondents and assessed core DSM-IV mental disorders (n=130,485 respondents across all surveys). Part II assessed additional disorders and correlates and was administered to 100% of respondents who met lifetime criteria for any Part I disorder and a probability subsample of other Part I respondents (n=69,524).
Measures
Social Anxiety Disorder (SAD):
Diagnoses were based on Version 3.0 of the WHO’s Composite International Diagnostic Interview (CIDI-3.0) [21], a fully structured lay-administered diagnostic interview. The DSM-IV criteria were used to define SAD. Respondents were administered the full SAD section if they endorsed a diagnostic stem question for one or more performance or interactional fears described as excessive and causing substantial distress or avoidance. The SAD section screened for lifetime experiences of shyness, fear, and discomfort associated with each of 14 social situations (such as interaction with unfamiliar people, starting conversations, attending parties, going to work or school, making eye contact, or dating) using the following question “Was there ever a time in your life when you had a strong fear of social or performance situations like giving a speech, meeting new people, going to parties,…?”. Respondents endorsing one or more such questions were asked about all DSM-IV criteria for both lifetime and 12-month SAD. Age of onset (AOO) of each disorder was assessed using special probing techniques shown experimentally to improve recall accuracy [20]. All diagnoses excluded cases with plausible organic causes. Clinical reappraisal interviews were carried out in several countries using the lifetime non-patient version of the Structured Clinical Interview for DSM-IV (SCID) [22] as the gold standard. Concordance is fair (AUC in the range 0.6–0.7) for SAD. The majority of SCID cases are detected by the CIDI-3.0 for anxiety disorders, including SAD (54.4%). Fair agreement was found between diagnoses of SAD based on the CIDI-3.0 and blinded SCID clinician-administered reappraisal interviews (κ=0.35), with the CIDI-3.0 showing low sensitivity (0.37) but fairly high specificity (0.94) [23].
Perceived helpfulness of treatment for SAD.
Respondents who met lifetime DSM-IV/CIDI criteria for SAD were asked retrospectively about age-of-onset and were then asked “Did you ever in your life talk to medical doctor or other professional about your fear (or avoidance) of these situations?” and, if so, “How old were you the first time you talked to a professional about your fear?”. “Other professionals” were defined broadly to include “psychologists, counselors, spiritual advisors, herbalists, acupuncturists, and other healing professionals.” Respondents who said they talked to a professional were then asked, “Did you ever get treatment for your fear or avoidance of these situations that you considered helpful or effective?” If they said yes, they were asked “How many professionals did you ever talk to about your fear up to and including the first time you ever got helpful treatment?” If they said no, they were asked “How many professionals did you ever talk to about your fear…?”
Predictor variables.
There were 4 groups of predictor variables included in the equations: sociodemographic variables, treatment type, lifetime mental disorders, and early childhood adversities. Socio-economic characteristics included age at first SAD treatment (continuous), sex, marital status (married, never married, previously married) at the time of first SAD treatment, and education (in quartiles defined by within-country distributions) at the time of first treatment. Treatment type was defined as the cross-classification of variables for: (i) whether the respondent reported receiving medication, talk therapy, or both, as of the age of first treatment; and; (ii) types of treatment providers seen as of that age, including mental health specialists (psychiatrist, psychiatric nurse, psychologist, psychiatric social worker, mental health counselor), primary care providers, human services providers (social worker or counselor in a social services agency, spiritual advisor), and complementary/alternative medicine providers (other type of healer or self-help group). Treatment timing included a dichotomous measure for whether the respondent’s first attempt to seek treatment occurred before 2000 or subsequently (2000 being the average mid-point between the start of observation and survey field dates) and a continuous variable for length of delay in years between age-of-onset of SAD and age of initially seeking treatment. Lifetime mental disorders were assessed with the CIDI-3.0 included anxiety disorders (including generalized anxiety disorder, panic disorder, agoraphobia with or without panic disorder, post-traumatic stress disorder, specific phobia, as well as the number of lifetime anxiety disorder: 1, 2, or 2+ disorders), mood disorders (major depressive disorder and bipolar disorder), and substance use disorder (alcohol and/or drug abuse with or without dependence). Lifetime comorbid conditions included number of anxiety disorders, mood, and substance use disorders with first onsets prior to the age of first treatment, which were thought to confer an increased mental health burden of SAD [24,25]. Childhood adversities included separate counts of a correlated set of adversities we have referred to previous as those indicative of maladaptive family functioning (including physical abuse, sexual abuse, neglect, parental mental disorder, parental substance use disorder, parental criminal behavior, and family violence) and other childhood adversities (including parental death, parental divorce, other loss of a parent, physical illness, and economic adversity) [26] (see Appendix Table 1). The childhood adversity count variables were scored in the range 0-7 for family dysfunction and 0-5 for other adversities and were treated as linear variables in the analysis.
Analysis methods
The analysis sample was limited to people with onset of lifetime DSM-IV SAD treatment during or after 1990 to reduce the potential effects of recall bias. The number of respondents in the sample with prior SAD treatment across countries was n=667. To investigate the two components of helpful treatment separately, we used discrete- event survival analysis to calculate the conditional and cumulative probabilities of: (i) obtaining helpful treatment after seeing between 1 and 7 professionals; and (ii) persisting in seeking treatment with between 2 and 7 professionals after obtaining prior unhelpful treatment (2). We followed respondents up through 7 professionals because this was the last number where our required minimum of at least n=30 received treatment. We then carried out parallel survival analyses of the predictors of these two component outcomes using standard discrete-time methods and a logistic link function [27], followed by a person-level model of overall probability of ever receiving helpful treatment regardless of number of professionals seen.
Individual weights were applied to adjust for probability of selection, nonresponse and post-stratification. In addition, Part II respondents were weighted to adjust for differential probabilities of selection into Part II and deviations between the sample and population demographic-geographic distributions [28]. Because the WMH sample designs used weighting and clustering, all statistical analyses were carried out using the Taylor series linearization method [29], a design-based method implemented in the SAS 9.4 program (SAS/STAT, 2016). Logistic regression coefficients and +/− 2 of their design-based standard errors were exponentiated to create adjusted odds-ratios (ORs) (i.e. adjusted for all other variables in the model) and 95% confidence intervals (CIs). Significance of sets of coefficients was evaluated with Wald χ2 tests based on design-corrected coefficient variance-covariance matrices. Statistical significance was evaluated consistently using two-sided design-based .05 level tests.
RESULTS
Perceived helpfulness of treatment
Across countries, lifetime treatment among adults with lifetime DSM-IV SAD (i.e. 4.6%) was estimated at 22.8%. Among these, 65.1% reported ever obtaining treatment they considered helpful (Table 1). Treatment probabilities were considerably higher in high compared to low/middle-income countries (24.8% vs. 15.8%) but the proportions of respondents that experienced the treatment as helpful was relatively similar (65.9% in high vs. 60.4% in low/middle-income countries).
Table 1.
Lifetime prevalence of DSM-IV social anxiety disorder (SAD), lifetime proportion of cases who obtained treatment and perceived treatment as helpful, and proportion of treated cases who perceived treatment as helpful
| In the entire sample |
Among respondents with lifetime SAD |
Among respondents with lifetime SAD |
Among cases that obtained lifetime SAD treatmenta |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| % of lifetime SAD |
% of obtaining treatmenta |
% of perceived treatment as helpfulb |
% of perceived treatment as helpfulb |
|||||||||
| n | % | (SE) | n | % | (SE) | n | % | (SE) | n | % | (SE) | |
|
|
|
|
|
|||||||||
| Low and Middle Income Countries | ||||||||||||
| Colombia | 4426 | 5.0 | (0.5) | 219 | 13.9 | (3.3) | 219 | 6.8 | (2.4) | 31 | 49.0 | (12.9) |
| Iraq | 4332 | 0.8 | (0.2) | 35 | 22.7 | (11.1) | 35 | 21.1 | (10.9) | 6 | 92.8 | (7.9) |
| Peru | 3930 | 2.6 | (0.3) | 95 | 18.9 | (4.2) | 95 | 7.5 | (2.7) | 18 | 39.7 | (11.1) |
| Shenzhen, PRC | 7132 | 0.9 | (0.2) | 66 | 18.4 | (7.1) | 66 | 12.1 | (6.0) | 8 | 65.8 | (20.4) |
| Sao Paulo, Brazil | 5037 | 5.6 | (0.4) | 256 | 21.2 | (2.9) | 256 | 13.7 | (3.3) | 51 | 64.6 | (10.9) |
| Bulgaria | 6826 | 0.9 | (0.2) | 56 | 12.0 | (3.5) | 56 | 4.1 | (3.1) | 7 | 34.4 | (18.6) |
| Lebanon | 2857 | 1.9 | (0.4) | 52 | 5.7 | (3.5) | 52 | 2.8 | (2.7) | 3 | 48.7 | (31.5) |
| Medellin, Colombia | 3261 | 4.6 | (0.5) | 137 | 10.5 | (3.0) | 137 | 6.1 | (2.4) | 18 | 58.1 | (15.0) |
| Mexico | 5782 | 2.9 | (0.2) | 203 | 13.5 | (3.2) | 203 | 9.8 | (2.8) | 27 | 72.9 | (9.9) |
| Romania | 2357 | 1.3 | (0.3) | 29 | 19.5 | (7.7) | 29 | 17.1 | (7.7) | 5 | 87.6 | (12.1) |
| High Income Countries | ||||||||||||
| Argentina | 3927 | 2.6 | (0.3) | 111 | 31.8 | (5.0) | 111 | 18.2 | (3.4) | 40 | 57.2 | (11.7) |
| Australia | 8463 | 8.5 | (0.4) | 740 | 40.7 | (2.5) | 740 | 27.3 | (2.2) | 302 | 67.0 | (3.5) |
| Belgium | 1043 | 2.1 | (0.5) | 37 | 15.7 | (5.6) | 37 | 13.2 | (5.0) | 11 | 83.6 | (8.4) |
| France | 1436 | 4.7 | (0.7) | 96 | 21.9 | (6.2) | 96 | 3.6 | (1.6) | 28 | 16.5 | (7.3) |
| Germany | 1323 | 2.9 | (0.5) | 68 | 23.2 | (5.2) | 68 | 12.3 | (3.9) | 26 | 52.8 | (10.4) |
| Italy | 1779 | 2.1 | (0.3) | 73 | 18.0 | (6.3) | 73 | 9.1 | (4.0) | 12 | 50.4 | (19.9) |
| Japan | 4129 | 1.4 | (0.2) | 53 | 16.4 | (6.8) | 53 | 11.5 | (4.9) | 7 | 70.5 | (22.7) |
| Murcia, Spain | 2621 | 1.7 | (0.2) | 43 | 31.7 | (10.3) | 43 | 29.8 | (10.3) | 15 | 94.1 | (4.9) |
| Netherlands | 1094 | 2.4 | (0.5) | 59 | 32.5 | (6.5) | 59 | 24.1 | (6.7) | 19 | 74.0 | (7.8) |
| New Zealand | 12790 | 9.5 | (0.3) | 1283 | 22.8 | (1.5) | 1283 | 15.5 | (1.1) | 278 | 67.9 | (3.4) |
| Northern Ireland | 4340 | 6.0 | (0.4) | 283 | 32.5 | (3.2) | 283 | 21.7 | (2.6) | 88 | 66.7 | (6.0) |
| Poland | 10081 | 1.4 | (0.1) | 144 | 19.4 | (2.8) | 144 | 14.0 | (2.4) | 28 | 72.3 | (7.2) |
| Portugal | 3849 | 4.7 | (0.5) | 188 | 22.6 | (3.2) | 188 | 13.4 | (2.5) | 42 | 59.1 | (8.2) |
| Spain | 2121 | 1.3 | (0.3) | 53 | 31.5 | (5.9) | 53 | 23.0 | (5.5) | 17 | 73.0 | (8.6) |
| US | 9282 | 12.1 | (0.4) | 1143 | 18.0 | (1.1) | 1143 | 12.3 | (1.1) | 212 | 68.2 | (3.0) |
| Saudi Arabia | 3638 | 5.5 | (0.6) | 164 | 11.6 | (3.5) | 164 | 4.0 | (1.5) | 23 | 34.1 | (13.0) |
| All Low and Middle Income Countries | 45940 | 2.5 | (0.1) | 1148 | 15.8 | (1.3) | 1148 | 9.5 | (1.2) | 174 | 60.4 | (5.1) |
| All High Income Countries | 71916 | 5.9 | (0.1) | 4538 | 24.8 | (0.8) | 4538 | 16.3 | (0.6) | 1148 | 65.9 | (1.7) |
| All Countries | 117856 | 4.6 | (0.1) | 5686 | 22.8 | (0.7) | 5686 | 14.9 | (0.6) | 1322 | 65.1 | (1.6) |
| χ2 Test on | DF | χ2 | P-value | DF | χ2 | P-value | DF | χ2 | P-value | DF | χ2 | P-value |
|
|
|
|
|
|||||||||
| Low and Middle Income Countries | 9 | 244.5 | <.0001* | 9 | 12.7 | 0.175 | 9 | 11.6 | 0.235 | 9 | 12.5 | 0.188 |
| High Income Countries | 15 | 1400.9 | <.0001* | 15 | 108.6 | <.0001* | 15 | 90.8 | <.0001* | 15 | 38.8 | 0.001* |
| All Countries | 25 | 1956.2 | <.0001* | 25 | 144.2 | <.0001* | 25 | 119.9 | <.0001* | 25 | 53.5 | 0.001* |
| Low and Middle vs. High | 1 | 398.0 | <.0001* | 1 | 26.9 | <.0001* | 1 | 17.4 | <.0001* | 1 | 1.1 | 0.298 |
Abbreviations: SE, standard error; PRC, People’s Republic of China
Cases are based on three conditions: (i) Respondents obtained SAD treatment; (ii) Year of first SAD treatment was 1990 or later; and (iii) Age at onset was the year of first SAD treatment or earlier.
Cases are based on four conditions: (i) Respondents obtained SAD treatment; (ii) Year of first SAD treatment was 1990 or later; (iii) Age at onset was the year of first SAD treatment or earlier; and (iv) Respondents obtained helpful treatment.
Helpful SAD treatment by type of professional seen
Across countries, 24.9% said they were helped by the first professional seen (Table 2, left panel). The conditional probability of a second professional being helpful after the previous unhelpful treatment was 31.8%, and 34.3% for a third professional, with a decline further after each subsequent professional seen, and then an increase to 47.2% for the seventh professional seen. The cumulative probability of receiving helpful treatment rose from 24.9% after the first professional seen to 48.8% if they persevered in trying a second professional after unhelpful treatment from the first, with 92.2% projected to receive helpful treatment if they persevered in trying up to 7 professionals after earlier ones were unhelpful (Table 2, right panel). Patterns and probabilities were generally similar across country income levels, with a tendency of a higher cumulative perceived helpfulness in low/middle-income countries.
Table 2.
Conditional and cumulative probabilities of social anxiety disorder (SAD) treatment being perceived as helpful after each professional seen, among respondents with lifetime DSM-IV SAD who obtained treatment
| I. Conditional probabilities | II. Cumulative probabilities | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
||||||||||||||
| Number of professionals seen after which treatment was perceived as helpful | All | High-income countries | Low/middle income countries | All (n=1322) | High-income countries (n=1148) | Low/middle income countries (n=174) | |||||||||
|
|
|
|
|
|
|
||||||||||
| n | % | (SE) | n | % | (SE) | n | % | (SE) | % | (SE) | % | (SE) | % | (SE) | |
|
|
|
|
|
|
|
||||||||||
| 1 | 1322 | 24.9 | (1.2) | 1148 | 23.3 | (1.3) | 174 | 33.9 | (3.1) | 24.9 | (1.2) | 23.3 | (1.3) | 33.9 | (3.1) |
| 2 | 746 | 31.8 | (1.9) | 680 | 32.4 | (2.1) | 66 | 27.0 | (4.4) | 48.8 | (1.8) | 48.1 | (2.0) | 51.8 | (5.1) |
| 3 | 428 | 34.3 | (2.5) | 389 | 34.4 | (2.7) | 39 | 33.4 | (7.4) | 66.3 | (1.9) | 66.0 | (2.0) | 67.9 | (5.7) |
| 4 | 230 | 24.6 | (3.0) | 211 | 23.7 | (3.3) | 19 | 31.7 | (4.9) | 74.6 | (1.9) | 74.0 | (2.0) | 78.0 | (5.5) |
| 5 | 145 | 27.3 | (4.6) | 134 | 28.7 | (5.0) | 11 | 15.0 | (3.8) | 81.6 | (1.7) | 81.5 | (1.8) | 81.3 | (5.6) |
| 6 | 90 | 20.2 | (4.0) | 86 | 18.0 | (4.2) | 4 | 43.5 | (17.3) | 85.3 | (1.6) | 84.8 | (1.7) | 89.5 | (5.9) |
| 7 | 60 | 47.2 | (8.2) | 57 | 45.9 | (8.5) | 3 | 65.4 | (28.1) | 92.2 | (1.3) | 91.8 | (1.4) | 96.4 | (2.9) |
Abbreviations: SE, standard error.
Persistence of help-seeking following treatment failure for SAD
The vast majority (all in the 75-85% range) of respondents who were not helped by an initial professional eventually persisted in seeing another professional (Table 3, left panel). However, since not everyone persisted after each unhelpful attempt, the cumulative probability of persisting up through seven professionals was close to one in three (30.2% - see Table 3, right panel). Patterns were generally similar across country income levels, except for the proportion of respondents that persisted in seeing professionals; this was remarkably lower in low/middle-income countries compared to high-income countries.
Table 3.
Conditional and cumulative probability of persistence with treatment after previous unhelpful attempts, among respondents with lifetime DSM-IV social anxiety disorder (SAD) who obtained treatment
| Number of professionals seen if not helped by the previous one | I. Conditional probabilities | II. Cumulative probabilities | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
||||||||||||||
| All |
High-income countries |
Low/middle income countries |
All (n=991) |
High-income countries (n=876) |
Low/middle income countries (n=115) |
||||||||||
| n | % | (SE) | n | % | (SE) | n | % | (SE) | % | (SE) | % | (SE) | % | (SE) | |
|
|
|
|
|
|
|
||||||||||
| 2 | 991 | 74.6 | (1.6) | 876 | 77.3 | (1.7) | 115 | 56.6 | (4.9) | 74.6 | (1.6) | 77.3 | (1.7) | 56.6 | (4.9) |
| 3 | 520 | 80.9 | (1.7) | 473 | 80.1 | (1.9) | 47 | 87.4 | (1.9) | 60.3 | (2.2) | 61.9 | (2.3) | 49.5 | (6.6) |
| 4 | 284 | 82.3 | (2.1) | 257 | 82.5 | (2.3) | 27 | 80.8 | (4.5) | 49.6 | (2.4) | 51.0 | (2.6) | 40.0 | (6.8) |
| 5 | 173 | 85.2 | (2.1) | 160 | 85.2 | (2.3) | 13 | 85.5 | (3.1) | 42.3 | (2.7) | 43.5 | (2.9) | 34.2 | (7.3) |
| 6 | 109 | 84.2 | (3.3) | 101 | 88.0 | (2.9) | 8 | 57.5 | (14.6) | 35.6 | (2.7) | 38.3 | (2.8) | 19.7 | (8.6) |
| 7 | 69 | 84.6 | (4.4) | 66 | 83.7 | (4.6) | 3 | 100.0 | (0.0) | 30.2 | (2.9) | 32.0 | (3.1) | 19.7 | (8.6) |
Abbreviations: SE, standard error.
Predictors of perceived helpfulness
Table 4 shows the results of three multivariate models (all countries together) predicting whether treatment from a provider was helpful, pooled across all professionals seen by each patient (Model 1), whether respondents persisted in help-seeking after previous unhelpful treatment pooled across subsequent professionals seen after an earlier unhelpful professional (Model 2), and whether helpful treatment was obtained at the person-level regardless of number of treatment providers seen (Model 3). We focus on how the results from the pooled models help explain the associations in the person-level model. In general, predictors of perceived helpfulness were similar across income countries, except that in low-/middle-income countries we found a lower number of predictors of each of the outcomes. After adjustment for all other variables in the model, perceived helpfulness (at the person-level) was higher in those respondents who were currently married at the time of treatment. Disaggregation into the two components of perceived helpfulness shows that marital status was more related to helpful treatment than to increased persistence after unhelpful treatment.
Table 4.
Predictors of helpful treatment and persistence (pooled across professionals seen), and predictors of perceived helpfulness of treatment (person level), among people with lifetime DSM-IV social anxiety disorder (SAD) who obtained treatment
| Model 1: Predicting helpful treatment pooled across professionals seen (n=3180) |
Model 2: Predicting persistence pooled across treatment failure (n=2324) |
Model 3: Predicting perceived helpfulness of treatment across SAD patients (n=1322) |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence | Multivariate | Prevalence | Multivariate | Prevalence | Multivariate | |||||||
|
|
|
|
||||||||||
| Mean/% | (SE) | AOR | (95% CI) | Mean/% | (SE) | AOR | (95% CI) | Mean/% | (SE) | AOR | (95% CI) | |
|
|
|
|
||||||||||
| Age | ||||||||||||
| Age at first SAD treatment | 30.1 | (0.5) | 1.01 | (1.00-1.02) | 29.8 | (0.5) | 1.01 | (0.99-1.02) | 30.6 | (0.4) | 1.01 | (0.99-1.03) |
| χ21 (p-value) | 1.1 (0.29) | 1.1 (0.28) | 0.9 (0.35) | |||||||||
| Gender | ||||||||||||
| Female | 59.1 | (2.5) | 1.25* | (1.03-1.52) | 58.0 | (2.9) | 0.98 | (0.74-1.30) | 60.4 | (1.5) | 1.20 | (0.88-1.65) |
| Male | 40.9 | (2.5) | 1.0 | 42.0 | (2.9) | 1.0 | 39.6 | (1.5) | 1.0 | |||
| χ21 (p-value) | 5.3 (0.021)* | 0.0 (0.87) | 1.3 (0.26) | |||||||||
| Marital Status | ||||||||||||
| Never married | 51.8 | (1.9) | 0.95 | (0.76-1.19) | 52.0 | (2.2) | 0.72 | (0.51-1.02) | 53.8 | (1.2) | 0.68* | (0.47-0.98) |
| Previously married | 18.5 | (1.4) | 0.64* | (0.48-0.84) | 19.3 | (1.7) | 0.82 | (0.52-1.28) | 17.0 | (1.1) | 0.53* | (0.33-0.83) |
| Currently married | 29.7 | (2.3) | 1.0 | - | 28.7 | (2.8) | 1.0 | - | 29.1 | (1.2) | 1.0 | - |
| χ22 (p-value) | 11.7 (0.003)* | 3.4 (0.18) | 8.8 (0.012)* | |||||||||
| Education | ||||||||||||
| Low | 8.4 | (0.9) | 0.96 | (0.69-1.33) | 8.1 | (1.0) | 0.77 | (0.49-1.21) | 9.5 | (1.0) | 0.86 | (0.55-1.35) |
| Low-average | 19.1 | (1.7) | 0.86 | (0.65-1.12) | 19.1 | (1.9) | 1.08 | (0.71-1.65) | 18.3 | (1.1) | 0.95 | (0.61-1.47) |
| High-average | 37.0 | (2.1) | 0.80* | (0.65-0.99) | 37.2 | (2.4) | 1.25 | (0.88-1.76) | 35.2 | (1.3) | 0.95 | (0.66-1.39) |
| Student | 17.6 | (1.6) | 0.59* | (0.45-0.78) | 19.1 | (1.9) | 1.31 | (0.84-2.05) | 16.3 | (1.1) | 0.76 | (0.47-1.23) |
| High | 18.0 | (1.3) | 1.0 | - | 16.5 | (1.4) | 1.0 | - | 20.7 | (1.2) | 1.0 | - |
| χ24 (p-value) | 14.9 (0.005)* | 5.7 (0.22) | 1.7 (0.79) | |||||||||
| Treatment delay (years)a | 14.6 | (0.5) | 1.01 | (1.00-1.02) | 14.2 | (0.6) | 0.98* | (0.97-0.99) | 15.5 | (0.4) | 0.99 | (0.98-1.01) |
| χ21 (p-value) | 3.2 (0.07) | 10.2 (0.001)* | 1.0 (0.33) | |||||||||
| Started SAD treatment >= 2000 (vs. 1990-1999) | 42.3 | (2.2) | 1.59* | (1.34-1.89) | 39.4 | (2.5) | 0.63* | (0.49-0.83) | 50.0 | (1.6) | 1.01 | (0.77-1.32) |
| χ21 (p-value) | 27.8 (<.001)* | 11.3 (<.001)* | 0.0 (0.96) | |||||||||
| Treatment Typeb | ||||||||||||
| Mental health specialist + Psychotherapy | 64.2 | (1.9) | 0.76* | (0.58-0.99) | 64.6 | (2.1) | 1.27 | (0.85-1.90) | 61.9 | (1.5) | 0.92 | (0.60-1.42) |
| Mental health specialist + Medication | 69.2 | (1.8) | 0.66* | (0.52-0.85) | 71.4 | (1.8) | 1.83* | (1.31-2.56) | 57.9 | (1.6) | 1.23 | (0.85-1.79) |
| General medical | 73.9 | (1.7) | 0.64* | (0.50-0.82) | 75.7 | (1.9) | 0.94 | (0.66-1.35) | 68.5 | (1.3) | 0.67* | (0.48-0.93) |
| Complementary/alternative medicine | 32.3 | (2.2) | 0.86 | (0.70-1.06) | 33.5 | (2.6) | 1.35 | (0.97-1.88) | 26.0 | (1.2) | 1.11 | (0.78-1.57) |
| Human services | 20.9 | (2.4) | 1.0 | - | 22.7 | (2.8) | 1.0 | - | 15.2 | (1.1) | 1.0 | - |
| χ24 (p-value) | 17.5 (0.002)* | 20.6 (<.001)* | 9.5 (0.05) | |||||||||
| Exactly 2 or more of the above | 78.4 | (1.5) | 1.37 | (0.94-2.00) | 79.6 | (1.7) | 1.80* | (1.15-2.82) | 69.3 | (1.5) | 1.81* | (1.06-3.10) |
| χ21 (p-value) | 2.7 (0.10) | 6.7 (0.010)* | 4.7 (0.031)* | |||||||||
| χ25 (p-value) | 21.8 (<.001)* | 73.0 (<.001)* | 21.9 (<.001)* | |||||||||
| Number of lifetime anxiety disordersc | ||||||||||||
| 3 or morec | 40.1 | (2.2) | 0.87 | (0.70-1.08) | 41.8 | (2.6) | 2.32* | (1.72-3.12) | 32.0 | (1.2) | 1.83* | (1.30-2.57) |
| Exactly 2c | 32.1 | (1.9) | 1.13 | (0.94-1.37) | 31.0 | (2.1) | 1.41* | (1.04-1.90) | 34.1 | (1.4) | 1.50* | (1.09-2.06) |
| Exactly 1c | 27.9 | (1.7) | 1.0 | - | 27.2 | (1.8) | 1.0 | - | 34.0 | (1.4) | 1.0 | - |
| χ22 (p-value) | 7.3 (0.027)* | 31.5 (<.001)* | 14.5 (<.001)* | |||||||||
| Mood disorder | ||||||||||||
| Major depressive disorder | 42.5 | (2.1) | 1.01 | (0.84-1.21) | 42.1 | (2.5) | 1.22 | (0.91-1.63) | 40.5 | (1.4) | 1.23 | (0.91-1.67) |
| Bipolar disorder | 14.9 | (2.4) | 0.84 | (0.63-1.14) | 16.3 | (3.0) | 0.87 | (0.61-1.24) | 11.7 | (0.80 | 0.84 | (0.56-1.29) |
| Substance use disorder | ||||||||||||
| χ22 (p-value) | 1.3 (0.51) | 3.4 (0.18) | 3.2 (0.20) | |||||||||
| Alcohol and/or drug abuse | 26.8 | (2.6) | 1.04 | (0.81-1.32) | 27.6 | (3.2) | 1.11 | (0.78-1.57) | 23.8 | (1.3) | 1.12 | (0.77-1.64) |
| Alcohol or drug dependence but not abuse | 3.9 | (0.9) | 0.73 | (0.45-1.17) | 4.4 | (0.8) | 1.55 | (0.94-2.57) | 2.7 | (0.4) | 0.92 | (0.48-1.78) |
| χ22 (p-value) | 2.1 (0.35) | 3.0 (0.23) | 0.6 (0.74) | |||||||||
| χ26 (p-value) | 13.9 (0.031)* | 41.7 (<.001)* | 17.8 (0.007)* | |||||||||
| Childhood Adversities | ||||||||||||
| Family Dysfunctiond | 34.7 | (2.3) | 0.80* | (0.65-0.98) | 35.8 | (2.7) | 0.80 | (0.59-1.10) | 33.7 | (1.3) | 0.64* | (0.46-0.88) |
| Othere | 18.2 | (2.5) | 0.95 | (0.69-1.30) | 18.6 | (3.2) | 1.18 | (0.82-1.69) | 16.8 | (1.1) | 1.06 | (0.69-1.61) |
| χ22 (p-value) | 5.4 (0.07) | 2.0 (0.38) | 8.0 (0.018)* | |||||||||
| Global χ223 | 132.1 (<.001)* | 326.2 (<.001)* | 85.6 (<.001)* | |||||||||
Abbreviations: SE, standard error; AOR, adjusted odds ratio; CI, confidence interval.
Significant at .05 level, two-sided test.
Treatment delay (years) = Age at first SAD treatment – Age at onset of SAD.
Treatment providers: mental health specialists (psychiatrist, psychiatric nurse, psychologist, psychiatric social worker, mental health counselor), primary care providers, human services providers (social worker or counselor in a social services agency, spiritual advisor), and complementary/alternative medicine (other type of healer or self-help group).
Lifetime anxiety disorders include generalized anxiety disorder, panic disorder, agoraphobia with or without panic disorder, post-traumatic stress disorder, specific phobia and social anxiety disorder.
Family Dysfunction includes Physical abuse, Sexual abuse, Neglect, Parent mental disorder, Parent substance use disorder, Parent criminal behavior and Family violence.
Other includes Parent death, Parent divorce, Other loss of a parent, Physical illness and Economic adversity.
Receiving treatment from a general medical provider decreased (aOR=0.67; 95%CI=0.48-0.93) the odds of perceiving treatment as helpful, mainly due to a decreased helpful treatment (aOR=0.64; 95%CI=0.50-0.82) and not through lower persistence (aOR=0.94; 95%CI=0.66-1.35).
Also, treatment by more than one type increased the odds of perceiving treatment as helpful (aOR=1.81; 95%CI=1.06-3.10), through increased persistence after a previous unhelpful treatment (aOR=1.80; 95%CI=1.15-2.82) but not through helpful treatment of a given professional (aOR=1.37; 95%CI=0.94-2.00). Helpful treatment of a given professional was lower in respondents receiving treatment from formal healthcare providers (aORs between 0.64 and 0.76; all p≤0.05).
Mental health specialist treatment (including medication) was associated with higher persistence after previous unhelpful treatment (aOR=1.83; 95%CI=1.31-2.56) but also with lower odds of treatment of a given professional being perceived as helpful (aOR=0.66;95%CI=0.52-0.85). These opposite-sign effects cancelled each other out so that there was no significant overall effect in the model that predicted perceived helpfulness. Similarly, starting treatment in 2000 or later was associated with significantly elevated odds of treatment from a given professional being helpful (aOR=1.59; 95%CI=1.34-1.89), and also with significantly decreased odds of persistence following unhelpful treatment (aOR=0.63; 95%CI=0.49-0.83).
Perceived helpfulness was higher in respondents with lifetime anxiety disorders, with a dose-response gradient. Decomposition showed that this was due to increased persistence (aORs of 1.41 and 2.32, respectively, all p≤0.05) rather than treatment from a given professional being helpful (aOR=1.13 and aOR=0.87, respectively; all p≤0.05). Respondents with family dysfunction childhood adversities (such as physical or sexual abuse) had markedly lower odds of perceiving SAD treatment as helpful (aOR=0.64; 95%CI=0.46-0.88). Decomposition showed that this was due to a decreased odds of treatment from a given professional being helpful (aOR=0.80; 95%CI=0.65-0.98) and not to a lower persistence (aOR=0.80; 95%CI=0.59-1.10).
We also investigated potential time trends in the significant associations from Table 4 and found that there was a stronger association between never/previously married and decreased odds of treatment from a given professional being helpful since 2000 compared to before (see Appendix Table 2).
DISCUSSION
Across countries and across continents, only 22.8% of the respondents with lifetime SAD ever obtained treatment. Among these, cumulative probability of helpful treatment was 92.2%, if they persevered in trying up to 7 professionals, but only 1 in 3 persisted this long. Across countries combined, 65.1% of adults with a lifetime history of DSM-IV SAD who received treatment reported ever obtaining treatment they considered helpful. Perceiving treatment as helpful (across professionals seen) was higher in female respondents, those currently married, respondents with higher education, those who started treatment in 2000 or later, and those treated in non-formal healthcare settings. By comparison, persistence in seeking treatment (after treatment failure) was increased in respondents with shorter delays in seeking treatment, in those who started treatment prior to the year 2000, in those treated by 2 or more healthcare sectors, and those with 2 or more lifetime anxiety disorders.
Persistence in help-seeking for SAD is associated with greatly increased likelihood that treatment will be perceived as helpful. Although the effective uptake of treatment is low, we found encouraging data that, worldwide, approximately two-thirds of the SAD respondents (60% in low-/middle-income countries and 65% in high income countries) eventually obtained treatment they described as helpful, a finding that reflects previous studies on effectiveness [30] and perceived helpfulness of treatment for SAD (14). Yet we estimated that more than over 90% of respondents would have experienced treatment as helpful if they had persisted in trying up to seven healthcare professionals after earlier unsuccessful treatment. However, only 33% persisted their help-seeking attempts to that extent. Approximately 25% do not persist in early stages of treatment when they found that the initial treatment contact was not sufficient. This may be because this particular subgroup experienced less burden of their condition [31], and, so, may show less motivation to continue seeking treatment [32].
A central feature of our study was the information revealed by decomposing the perceived helpfulness measure into two components. In doing so it became clear that perceived helpfulness can be increased if people persist in seeking treatment after previous unhelpful attempts. Our measure did not allow us to investigate whether respondents who persist in continuing treatment after an unhelpful previous provider vs. those who did not were different in terms of their clinical or therapeutic expectations [14]. However, to the extent these groups are similar, many more respondents with SAD may receive treatment they consider helpful if they persisted after earlier treatment failures. Interestingly, comparable analyses using WHO-WMH data on major depressive disorder [17], post-traumatic stress disorder [33], and specific phobia [34] show similar findings with regard to perceived helpfulness of treatment for disorders with heterogeneous clinical phenomenological features, different clinical course, different age of onset, and different risk factor patterns. This suggests that the concept of perceived helpfulness with treatment for mental disorders may have a common underlying pattern across different types of disorders. However, more in-depth assessment and analyses of perceived helpfulness is warranted to evaluate the generality across clinical problems and perceptions over time.
The multivariate models show that perceived helpfulness was higher in married respondents and in those who have had more than one lifetime anxiety disorder, and that this was mainly due to increased likelihood of these respondents perceiving treatments as helpful and not to greater persistence in help-seeking after earlier unhelpful treatments. That married respondents reported higher perceived helpfulness reflects earlier studies [35], but the finding that a higher number of lifetime anxiety disorders is associated with higher perceived helpfulness is new. It may be that this is driven by disorder severity. More importantly, being treated by a non-formal professional treatment type (such as human services or complementary/alternative medicine) was associated with a higher probability of treatment being perceived as helpful, but not with persistence with help-seeking after unhelpful treatment. By contrast, higher persistence of help-seeking was associated with receiving specialized treatment from a mental health specialist employing medication. It is possible that the effectiveness of medication reduced symptom severity and engendered hope for better outcome and fosters persistence as well.
This study had several methodological limitations. First, it is plausible that our results could be biased because respondents with a history of severe SAD might have been less likely to participate in this study [36]. To the extent that this is the case, we may have underestimated the main outcomes, since our data suggest that a higher severity is associated with higher perceived helpfulness. Second, the measures of perceived helpfulness of treatment were based on a single question (rather than a standardized instrument) asking respondents about whether and when they “talk(ed) to” a professional about their SAD and follow-up questions about whether they ever received “helpful or effective” treatment and about the number of professionals talked to up to the time helpful-effective treatment was obtained. The use of a single question could readily lead to a biased response profile among respondents. We have no validation on whether the intervention consisted of therapeutic consultations, the type(s) or appropriateness of clinical activities undertaken, or how encounters with a team of professionals were counted. Nor do we know the underlying reasons why exactly a respondent evaluated treatment as helpful. The results are in keeping with other surveys cited previously. At the same time, perceived helpfulness as a construct warrants more attention with assessments that extend beyond the usual survey data involving selected questions. Third, our assessment of lifetime mental disorders might be biased. Prior research have suggested that recall of symptoms could be biased by respondents’ age at the moment of the interview [37]. Specifically, respondents who did not obtain treatment may have failed to recall their symptoms or recalled them as less problematic and this might have been related to age at interview, potentially underestimating the prevalence of SAD and overestimating the extent to which SAD treatment is helpful. We assume that telescoping (i.e., recalling past experiences as having occurred more recently than they did occur) may have possibly biased our estimates of lifetime mental disorders [38]. The WMH surveys attempt to minimize this kind of recall bias by using procedures to aid memory search [21]. And, as noted in the sample section, we limited the analysis to respondents whose first SAD treatment occurred no longer ago than 1990 to truncate the problem. But it must be acknowledged that the problem might still exist to some unknown extent. A last limitation pertains to the wide time span of data inclusion. Since time trends cannot be estimated reliably, we compared pooled within-country results between high- and lower income countries controlling for, but not interacting with, time. Along the same line, with the current set of countries it is impossible to establish the relative importance of the numerous contextual, environmental, socioeconomic, health system, and other variables that determine the utilization patterns we found. Hence, our conclusions result from pooled within-country analyses and their external validity is defined by the kinds of countries in the analysis. Also, national country-level analyses could yield relevant results that differ from the current aggregation, though they escape the scope of this publication.”.
Supplementary Material
Implications for clinical practice.
From a clinical viewpoint, the findings are encouraging insofar as they convey that continuation to seek treatment is advisable if the first treatment one receives is not helpful. It may be important to align expectations of both practitioners and patients that more than one treatment may be needed to achieve change that is considered helpful. Also, healthcare providers may consider endorsing or even suggesting that patients seek additional support from non-health professionals, as this seems to increase the probability of treatment being perceived as helpful, as does seeing more than on group of providers. Importantly, the likelihood for perceiving treatment helpful is not only related to these factors discussed above, but also reflects the necessity of evidence-based interventions provided by qualified clinicians that provide the treatments, in a context of strong therapeutic alliances and shared decision-making processes [39]. As clinical research is moving to develop individually targeted or personalized treatment, its success may be reflected in helping match patients to the optimal treatment and in that way reduce the need to persist through a number of treatments that have not been viewed as very helpful.
Funding Acknowledgements
The World Health Organization World Mental Health (WMH) Survey Initiative is supported by the United States National Institute of Mental Health (NIMH; R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the United States Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical Inc., GlaxoSmithKline, and Bristol-Myers Squibb. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis. None of the funders had any role in the design, analysis, interpretation of results, or preparation of this paper. The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of the World Health Organization, other sponsoring organizations, agencies, or governments.
The Argentina survey -- Estudio Argentino de Epidemiología en Salud Mental (EASM) -- was supported by a grant from the Argentinian Ministry of Health (Ministerio de Salud de la Nación) - (Grant Number 2002–17270/13 – 5). The 2007 Australian National Survey of Mental Health and Wellbeing is funded by the Australian Government Department of Health and Ageing. The São Paulo Megacity Mental Health Survey is supported by the State of São Paulo Research Foundation (FAPESP) Thematic Project Grant 03/00204-3. The Bulgarian Epidemiological Study of common mental disorders EPIBUL is supported by the Ministry of Health and the National Center for Public Health Protection. EPIBUL 2, conducted in 2016-17, is supported by the Ministry of Health and European Economic Area Grants. The Colombian National Study of Mental Health (NSMH) is supported by the Ministry of Social Protection. The Mental Health Study Medellín – Colombia was carried out and supported jointly by the Center for Excellence on Research in Mental Health (CES University) and the Secretary of Health of Medellín. The ESEMeD project is funded by the European Commission (Contracts QLG5-1999-01042; SANCO 2004123, and EAHC 20081308), (the Piedmont Region (Italy)), Fondo de Investigación Sanitaria, Instituto de Salud Carlos III, Spain (FIS 00/0028), Ministerio de Ciencia y Tecnología, Spain (SAF 2000-158-CE), Generalitat de Catalunya (2017 SGR 452; 2014 SGR 748), Instituto de Salud Carlos III (CIBER CB06/02/0046, RETICS RD06/0011 REM-TAP), and other local agencies and by an unrestricted educational grant from GlaxoSmithKline. Implementation of the Iraq Mental Health Survey (IMHS) and data entry were carried out by the staff of the Iraqi MOH and MOP with direct support from the Iraqi IMHS team with funding from both the Japanese and European Funds through United Nations Development Group Iraq Trust Fund (UNDG ITF). The World Mental Health Japan (WMHJ) Survey is supported by the Grant for Research on Psychiatric and Neurological Diseases and Mental Health (H13-SHOGAI-023, H14-TOKUBETSU-026, H16-KOKORO-013, H25-SEISHIN-IPPAN-006) from the Japan Ministry of Health, Labour and Welfare. The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation (L.E.B.A.N.O.N.) is supported by the Lebanese Ministry of Public Health, the WHO (Lebanon), National Institute of Health / Fogarty International Center (R03 TW006481-01), anonymous private donations to IDRAAC, Lebanon, and unrestricted grants from, Algorithm, AstraZeneca, Benta, Bella Pharma, Eli Lilly, Glaxo Smith Kline, Lundbeck, Novartis, OmniPharma, Pfizer, Phenicia, Servier, UPO. The Mexican National Comorbidity Survey (MNCS) is supported by The National Institute of Psychiatry Ramon de la Fuente (INPRFMDIES 4280) and by the National Council on Science and Technology (CONACyT-G30544-H), with supplemental support from the Pan American Health Organization (PAHO). Te Rau Hinengaro: The New Zealand Mental Health Survey (NZMHS) is supported by the New Zealand Ministry of Health, Alcohol Advisory Council, and the Health Research Council. The Northern Ireland Study of Mental Health was funded by the Health & Social Care Research & Development Division of the Public Health Agency. The Peruvian World Mental Health Study was funded by the National Institute of Health of the Ministry of Health of Peru. The Polish project Epidemiology of Mental Health and Access to Care –EZOP Project (PL 0256) was carried out by the Institute of Psychiatry and Neurology in Warsaw in consortium with Department of Psychiatry - Medical University in Wroclaw and National Institute of Public Health-National Institute of Hygiene in Warsaw and in partnership with Psykiatrist Institut Vinderen–Universitet, Oslo. The project was funded by the European Economic Area Financial Mechanism and the Norwegian Financial Mechanism. EZOP project was co-financed by the Polish Ministry of Health. The Portuguese Mental Health Study was carried out by the Department of Mental Health, Faculty of Medical Sciences, NOVA University of Lisbon, with collaboration of the Portuguese Catholic University, and was funded by Champalimaud Foundation, Gulbenkian Foundation, Foundation for Science and Technology (FCT) and Ministry of Health. The Romania WMH study projects “Policies in Mental Health Area” and “National Study regarding Mental Health and Services Use” were carried out by National School of Public Health & Health Services Management (former National Institute for Research & Development in Health), with technical support of Metro Media Transilvania, the National Institute of Statistics-National Centre for Training in Statistics, SC Cheyenne Services SRL, Statistics Netherlands and were funded by Ministry of Public Health (former Ministry of Health) with supplemental support of Eli Lilly Romania SRL. The Saudi National Mental Health Survey (SNMHS) is conducted by the King Salman Center for Disability Research. It is funded by Saudi Basic Industries Corporation (SABIC), King Abdulaziz City for Science and Technology (KACST), Ministry of Health (Saudi Arabia), and King Saud University. Funding in-kind was provided by King Faisal Specialist Hospital and Research Center, and the Ministry of Economy and Planning, General Authority for Statistics. The Shenzhen Mental Health Survey is supported by the Shenzhen Bureau of Health and the Shenzhen Bureau of Science, Technology, and Information. The Psychiatric Enquiry to General Population in Southeast Spain – Murcia (PEGASUS-Murcia) Project has been financed by the Regional Health Authorities of Murcia (Servicio Murciano de Salud and Consejería de Sanidad y Política Social) and Fundación para la Formación e Investigación Sanitarias (FFIS) of Murcia. The US National Comorbidity Survey Replication (NCS-R) is supported by the National Institute of Mental Health (NIMH; U01-MH60220) with supplemental support from the National Institute of Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF; Grant 044708), and the John W. Alden Trust. Dr. Jordi Alonso reports grants from the EU Commission, ISCIII/FEDER, and Generalitat de Catalunya, during the conduct of the study. Dr. Laura Helena Andrade is supported by the Brazilian Council for Scientific and Technological Development (CNPq Grant # 307933/2019-9). Dr. Corina Benjet reports grants from Consejo Nacional de Ciencia y Tecnología, during the conduct of the study.
A complete list of all within-country and cross-national WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/.
Conflicts of Interest
In the past 3 years, Dr. Kessler was a consultant for Datastat, Inc., Holmusk, RallyPoint Networks, Inc., and Sage Therapeutics. He has stock options in Mirah, PYM, and Roga Sciences. Dr. Navarro-Mateu reports non-financial support from Otsuka, outside the submitted work.
Footnotes
Ethics Approval
All procedures performed in studies involving human participants were approved by local Institutional Review Boards. The study is performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
Consent to Participate
The interview schedule was developed in English and translated into other languages using a standardized WHO translation, team translation, and harmonization protocol. Interviews were administered face-to-face in respondents’ homes after obtaining informed consent using procedures approved by local Institutional Review Boards.
Data Availability
Access to the cross-national World Mental Health (WMH) data is governed by the organizations funding and responsible for survey data collection in each country. These organizations made data available to the WMH consortium through restricted data sharing agreements that do not allow us to release the data to third parties. The exception is that the U.S. data are available for secondary analysis via the Inter-University Consortium for Political and Social Research (ICPSR), http://www.icpsr.umich.edu/icpsrweb/ICPSR/series/00527.
REFERENCES
- 1.Leichsenring F, Leweke F (2017) Social Anxiety Disorder. N Engl J Med 376 (23):2255–2264. doi: 10.1056/NEJMcp1614701 [DOI] [PubMed] [Google Scholar]
- 2.Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62 (6):617–627. doi: 10.1001/archpsyc.62.6.617 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Stein DJ, Lim CCW, Roest AM, de Jonge P, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Benjet C, Bromet EJ, Bruffaerts R, de Girolamo G, Florescu S, Gureje O, Haro JM, Harris MG, He Y, Hinkov H, Horiguchi I, Hu C, Karam A, Karam EG, Lee S, Lepine JP, Navarro-Mateu F, Pennell BE, Piazza M, Posada-Villa J, Ten Have M, Torres Y, Viana MC, Wojtyniak B, Xavier M, Kessler RC, Scott KM (2017) The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health Survey Initiative. BMC Med 15 (1):143. doi: 10.1186/s12916-017-0889-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, Olesen J, Allgulander C, Alonso J, Faravelli C, Fratiglioni L, Jennum P, Lieb R, Maercker A, van Os J, Preisig M, Salvador-Carulla L, Simon R, Steinhausen HC (2011) The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 21 (9):655–679. doi: 10.1016/j.euroneuro.2011.07.018 [DOI] [PubMed] [Google Scholar]
- 5.Patel A, Knapp M, Henderson J, Baldwin D (2002) The economic consequences of social phobia. J Affect Disord 68 (2-3):221–233. doi: 10.1016/s0165-0327(00)00323-2 [DOI] [PubMed] [Google Scholar]
- 6.Wittchen HU, Fuetsch M, Sonntag H, Müller N, Liebowitz M (2000) Disability and quality of life in pure and comorbid social phobia. Findings from a controlled study. Eur Psychiatry 15 (1):46–58. doi: 10.1016/s0924-9338(00)00211-x [DOI] [PubMed] [Google Scholar]
- 7.Bandelow B, Michaelis S (2015) Epidemiology of anxiety disorders in the 21st century. Dialogues in clinical neuroscience 17 (3):327–335. doi: 10.31887/DCNS.2015.17.3/bbandelow [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Koszycki D, Benger M, Shlik J, Bradwejn J (2007) Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behav Res Ther 45 (10):2518–2526. doi: 10.1016/j.brat.2007.04.011 [DOI] [PubMed] [Google Scholar]
- 9.Samantray N, Kar N, Singh P, Swain S, Singh A, Chaudhury S, Mahapatra J (2019) Efficacy of cognitive behavioral therapy with paroxetine and paroxetine only for social anxiety disorder: A behavioral, placebo-controlled study. Ind Psychiatry J 28 (2):211–217. doi: 10.4103/ipj.ipj_13_19 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Stein DJ, Vythilingum B (2007) Social anxiety disorder: psychobiological and evolutionary underpinnings. CNS Spectr 12 (11):806–809. doi: 10.1017/s1092852900015534 [DOI] [PubMed] [Google Scholar]
- 11.Andersson G, Cuijpers P, Carlbring P, Riper H, Hedman E (2014) Guided Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis. World Psychiatry 13 (3):288–295. doi: 10.1002/wps.20151 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Kazdin A (2017) Research design in clinical psychology. 5th edn. Pearson, Boston, MA [Google Scholar]
- 13.Kazdin AE (2006) Arbitrary metrics: Implications for identifying evidence-based treatments. Am Psychol 61 (1):42–49. doi: 10.1037/0003-066X.61.1.42 [DOI] [PubMed] [Google Scholar]
- 14.Hayes SA, Hope DA, VanDyke MM, Heimberg RG (2007) Working alliance for clients with social anxiety disorder: relationship with session helpfulness and within-session habituation. Cogn Behav Ther 36 (1):34–42. doi: 10.1080/16506070600947624 [DOI] [PubMed] [Google Scholar]
- 15.Shikatani B, Fredborg BK, Cassin SE, Kuo JR, Antony MM (2019) Acceptability and perceived helpfulness of single session mindfulness and cognitive restructuring strategies in individuals with social anxiety disorder: A pilot study. Can J Behav Sci 51 (2):83–89. doi: 10.1037/cbs0000121 [DOI] [Google Scholar]
- 16.Baggaley M (2020) Value-based healthcare in mental health services. BJPsych Adv 26:198–204 [Google Scholar]
- 17.Porter M, Teisberg E (2006) Redefining Health Care: Creating Value-Based Competition on Results. Harvard Business School Press, Boston, MA [Google Scholar]
- 18.Harris MG, Kazdin AE, Chiu WT, Sampson NA, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Altwaijri Y, Andrade LH, Cardoso G, Cía A, Florescu S, Gureje O, Hu C, Karam EG, Karam G, Mneimneh Z, Navarro-Mateu F, Oladeji BD, O’Neill S, Scott K, Slade T, Torres Y, Vigo D, Wojtyniak B, Zarkov Z, Ziv Y, Kessler RC (2020) Findings from World Mental Health surveys of the perceived helpfulness of treatment for patients with major depressive disorder. vol 77. American Medical Association, US. doi: 10.1001/jamapsychiatry.2020.1107 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Hamberger LK, Hindman M (2005) Collaborative Care of a Patient With Multiple, Chronic Physical and Emotional Health Problems. Clin Case Stud 4 (2):139–159. doi: 10.1177/1534650103259763 [DOI] [Google Scholar]
- 20.Hamai TA, Felitti VJ (2022) Adverse Childhood Experiences: Past, Present, and Future. In: Geffner R, White JW, Hamberger LK, Rosenbaum A, Vaughan-Eden V, Vieth VI (eds) Handbook of Interpersonal Violence and Abuse Across the Lifespan: A project of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV). Springer International Publishing, Cham, pp 97–120. doi: 10.1007/978-3-319-89999-2_305 [DOI] [Google Scholar]
- 21.Kessler RC, Ustün TB (2004) The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr 13 (2):93–121. doi: 10.1002/mpr.168 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.First M, Spitzer R, Gibbon M, Williams J (2002) Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Non-patient Edition (SCID-I/NP). Biometrics Research, New York State Psychiatric Institute, New York, NY [Google Scholar]
- 23.Haro JM, Arbabzadeh-Bouchez S, Brugha TS, de Girolamo G, Guyer ME, Jin R, Lepine JP, Mazzi F, Reneses B, Vilagut G, Sampson NA, Kessler RC (2006) Concordance of the Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health surveys. Int J Methods Psychiatr 15 (4):167–180. doi: 10.1002/mpr.196 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Coplan JD, Aaronson CJ, Panthangi V, Kim Y (2015) Treating comorbid anxiety and depression: Psychosocial and pharmacological approaches. World J Psychiatry 5 (4):366–378. doi: 10.5498/wjp.v5.i4.366 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Moffitt TE, Harrington H, Caspi A, Kim-Cohen J, Goldberg D, Gregory AM, Poulton R (2007) Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatry 64 (6):651–660. doi: 10.1001/archpsyc.64.6.651 [DOI] [PubMed] [Google Scholar]
- 26.Kessler RC, McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, Aguilar-Gaxiola S, Alhamzawi AO, Alonso J, Angermeyer M, Benjet C, Bromet E, Chatterji S, de Girolamo G, Demyttenaere K, Fayyad J, Florescu S, Gal G, Gureje O, Haro JM, Hu CY, Karam EG, Kawakami N, Lee S, Lépine JP, Ormel J, Posada-Villa J, Sagar R, Tsang A, Ustün TB, Vassilev S, Viana MC, Williams DR (2010) Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. BJPsych 197 (5):378–385. doi: 10.1192/bjp.bp.110.080499 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Willett JB, Singer JD (1993) Investigating onset, cessation, relapse, and recovery: why you should, and how you can, use discrete-time survival analysis to examine event occurrence. J Consult Clin Psychol 61 (6):952–965. doi: 10.1037//0022-006x.61.6.952 [DOI] [PubMed] [Google Scholar]
- 28.Heeringa S, Wells J, Hubbard F, Mneimneh Z, Chiu W, Sampson N, Berglund P (2008) Sample designs and sampling procedures. In: Kessler R, Ustün T (eds) The WHO World Mental Health Surveys: Global Perspectives On the Epidemiology of Mental Disorders. Cambridge University Press, New York, NY, pp 14–32 [Google Scholar]
- 29.K W (1985) Introduction to Variance Estimation. Springer-Verlag, New York, NY [Google Scholar]
- 30.Acarturk C, Cuijpers P, van Straten A, de Graaf R (2009) Psychological treatment of social anxiety disorder: a meta-analysis. Psychol Med 39 (2):241–254. doi: 10.1017/s0033291708003590 [DOI] [PubMed] [Google Scholar]
- 31.Bruffaerts R, Vilagut G, Demyttenaere K, Alonso J, AlHamzawi A, Andrade LH, Benjet C, Bromet E, Bunting B, de Girolamo G, Florescu S, Gureje O, Haro JM, He Y, Hinkov H, Hu C, Karam EG, Lepine J-P, Levinson D, Matschinger H, Nakane Y, Ormel J, Posada-Villa J, Scott KM, Varghese M, Williams DR, Xavier M, Kessler RC (2012) Role of common mental and physical disorders in partial disability around the world. Br J Psychiatry 200 (6):454–461. doi: 10.1192/bjp.bp.111.097519 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Turner SM, Beidel DC, Wolff PL, Spaulding S, Jacob RG (1996) Clinical features affecting treatment outcome in social phobia. Behav Res Ther 34 (10):795–804. doi: 10.1016/0005-7967(96)00028-9 [DOI] [PubMed] [Google Scholar]
- 33.Stein DJ, Harris MG, Vigo DV, Tat Chiu W, Sampson N, Alonso J, Altwaijri Y, Bunting B, Caldas-de-Almeida JM, Cía A, Ciutan M, Degenhardt L, Gureje O, Karam A, Karam EG, Lee S, Medina-Mora ME, Mneimneh Z, Navarro-Mateu F, Posada-Villa J, Rapsey C, Torres Y, Carmen Viana M, Ziv Y, Kessler RC (2020) Perceived helpfulness of treatment for posttraumatic stress disorder: Findings from the World Mental Health Surveys. Depress Anxiety 37 (10):972–994. doi: 10.1002/da.23076 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.de Vries YA, Harris MG, Vigo D, Chiu WT, Sampson NA, Al-Hamzawi A, Alonso J, Andrade LH, Benjet C, Bruffaerts R, Bunting B, Caldas de Almeida JM, de Girolamo G, Florescu S, Gureje O, Haro JM, Hu C, Karam EG, Kawakami N, Kovess-Masfety V, Lee S, Moskalewicz J, Navarro-Mateu F, Ojagbemi A, Posada-Villa J, Scott K, Torres Y, Zarkov Z, Nierenberg A, Kessler RC, de Jonge P (2021) Perceived helpfulness of treatment for specific phobia: Findings from the World Mental Health Surveys. J Affect Disord 288:199–209. doi: 10.1016/j.jad.2021.04.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Alang S, McAlpine D (2020) Treatment Modalities and Perceived Effectiveness of Treatment Among Adults With Depression. Health Serv Insights 13:1178632920918288–1178632920918288. doi: 10.1177/1178632920918288 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, Wittchen HU (2007) Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Archives of general psychiatry 64 (8):903–912. doi: 10.1001/archpsyc.64.8.903 [DOI] [PubMed] [Google Scholar]
- 37.Simon GE, VonKorff M (1995) Recall of psychiatric history in cross-sectional surveys: implications for epidemiologic research. Epidemiol Rev 17 (1):221–227. doi: 10.1093/oxfordjournals.epirev.a036180 [DOI] [PubMed] [Google Scholar]
- 38.Pickles A, Pickering K, Simonoff E, Silberg J, Meyer J, Maes H (1998) Genetic “clocks” and “soft” events: a twin model for pubertal development and other recalled sequences of developmental milestones, transitions, or ages at onset. Behav Genet 28 (4):243–253. doi: 10.1023/a:1021615228995 [DOI] [PubMed] [Google Scholar]
- 39.Maj M (2020) Helpful Treatment of Depression-Delivering the Right Messages. JAMA Psychiatry 77 (8):784–786. doi: 10.1001/jamapsychiatry.2020.0363 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Access to the cross-national World Mental Health (WMH) data is governed by the organizations funding and responsible for survey data collection in each country. These organizations made data available to the WMH consortium through restricted data sharing agreements that do not allow us to release the data to third parties. The exception is that the U.S. data are available for secondary analysis via the Inter-University Consortium for Political and Social Research (ICPSR), http://www.icpsr.umich.edu/icpsrweb/ICPSR/series/00527.