Globally, the prevalence of mental health disorders is increasing, accompanied by a greater need for accessible treatment. To inform policy responses, it is essential to understand both the scale of individuals with mental health disorders and the accessibility and quality of existing treatment.
The coverage cascade is a framework to measure the process of an individual receiving appropriate mental health care. Components of the coverage cascade include whether individuals have contact with a healthcare provider (contact coverage), whether they experience a certain minimum amount of care (minimally adequate coverage), and the quality of this provided care, given the individual’s mental health needs (effective coverage). Each stage of the cascade builds on the previous one and is associated with increased drop-out of individuals needing care, highlighting the importance of identifying both barriers to and opportunities to access mental health care.
To do so, Vigo et al. (2025) assessed the ratio of people with mental health disorders and whether they received effective treatment for this in 21 countries. Using data on the prevalence and severity of various DSM-IV mental health disorders, along with published standards for suitable treatment types, the study also examined individual and country-level variables, including perceived need for care, comorbidities, and local healthcare characteristics.
Globally rising rates of mental health disorders require accessible, high quality care, and the coverage cascade can help identify bottlenecks in mental health care systems worldwide.
Methods
World Mental Health surveys (2001–2019) were conducted face-to-face in 21 countries across income levels. “Ten surveys were in low- or middle-income countries, 2 each in Bulgaria and Colombia and 1 each in Lebanon, Mexico, Nigeria, Peru, Romania, and Brazil. Fifteen were in high-income countries, including Argentina, Belgium, France, Germany, Israel, Italy, Japan, the Netherlands, Northern Ireland, Poland (2), Portugal, Spain (2), and the US.”
Structured interviews assessed 12-month prevalence and severity of nine DSM-IV disorders (anxiety, mood, and substance use). Contact coverage was defined as seeing any healthcare professional, minimally adequate treatment by treatment type (pharmacotherapy/counselling), and effective treatment by disorder-specific standards. Individual factors (e.g., perceived need, sociodemographics, insurance) and country-level factors (e.g., socioeconomic status, healthcare system, stigma) were measured. Cross-tabulations estimated prevalence and treatment probabilities. Poisson regressions with country fixed effects and multilevel models assessed associations, controlling for a machine learning–derived disorder profile.
Results
Study Sample
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Total respondents analysed: 56,927 (weighted sample, oversampling people with mental disorders)
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12-month disorders: 12,508 respondents met criteria
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Analytic level: Person-disorder (18,702 cases)
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Demographics:
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52.1% female
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Median age: 41 years
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Prevalence of Mental Disorders
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Overall 12-month prevalence: 13.8%
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By disorder group:
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Most common individual disorders:
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Comorbidity: On average, respondents had 1.5 co-occurring conditions
Effective Treatment Coverage
Treatment Cascade
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Perceived need for treatment: 46.5% of people with disorders
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Treatment contact among those perceiving need: 34.1%
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Adequate care among those in treatment: 82.9%
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Effective treatment among those with adequate care: 47.0%
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Treatment contact without perceived need: 3.5% (often due to external pressure)
Individual-Level Predictors of Effective Treatment
Country-Level Predictors
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Associated with higher effective treatment:
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Greater healthcare resources
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Higher healthcare spending relative to GDP
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Human development indicators
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Not significant: Stigma and discrimination
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Remaining significant in multivariable models:
Multilevel Analyses
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Most predictors improved treatment coverage by increasing treatment contact among those perceiving need
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Gender and employment status also influenced both perceived need and treatment contact (even without perceived need)
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Composite disorder profile was associated with all intermediate outcomes, particularly treatment contact without perceived need.
Data of over 50,000 participants in 21 countries show that, among others, having an anxiety disorder, being female, comorbidities, and employment status are associated with higher chances of receiving effective treatment.
Conclusions
This study found that globally, the rate of people receiving effective treatment for their mental disorder is low, although this varies by disorder and through individual and country-specific factors.
The rates of receiving effective treatment are similar and highest for all anxiety disorders, whereas rates are lower and disorder-specific for mood and substance use disorders. The largest barrier to effective treatment is not having a perceived need for care, often preventing initial contact. Also, low contact coverage after indicating need and not receiving effective, disorder-specific treatment prevent effective treatment.
Being female, having healthcare insurance, multiple disorders, or living in a country with more healthcare spending were among factors that increased the chance of receiving effective treatment.
Rates of receiving effective treatment for mental health disorders are generally low and predominantly driven by a low perceived need for care.
Strengths and limitations
This study uses a large, cross-national sample spanning 21 countries, providing broad geographic and socioeconomic information. It also employs a rigorous analytic framework, measuring effective treatment by different important components, from initial contact through to disorder-specific effectiveness. The inclusion of both individual- and country-level factors further strengthens the analysis. However, the paper has a strong emphasis on policy relevance, despite the reality that mental health policy is rarely made at a global level. The absence of detailed country- or region-specific findings limits the applicability of the results for national or local decision-makers. Global patterns may offer a useful overview, but they often lack the specificity needed to actually inform actionable policy.
Another limitation is the timing of data collection, which spanned from 2001 to 2019. Given changes in prevalence but also public perceptions in global mental health, especially since COVID-19, some findings may no longer apply. While this limitation is not within the authors’ control, it could have been more explicitly acknowledged.
Moreover, some of the key outcomes, such as perceived need for treatment, are culturally dependent and may not be comparable across different countries or regions. For instance, cultural and religious norms significantly shape attitudes toward mental health, meaning that perceived need for care may be understood very differently in countries such as the Netherlands versus Nigeria. Investigating these cultural differences in perceiving mental health disorders and associated care could be informative to fully understand how they affect help-seeking behaviour and care access. In terms of outcome measures, the study defines effective treatment by the number of counselling sessions and/or receiving pharmacotherapy. While this makes sense, there is no data on whether patients report the treatment to be effective or a change in symptoms or diagnosis. Additionally, a rationale is missing why the specific 9 disorders were included in this paper. For example, it includes 5 different anxiety disorders, 2 mood related disorders, and notably, it groups all substance use disorder apart from alcohol into ‘drug use disorders’. This lacks nuance, as for example cannabis use disorder is quite different compared to cocaine use disorder. Therefore, the findings of this paper might be limited in that sense. Finally, while the paper is concise and data-rich, it assumes a high level of familiarity with health policy and related measurements. The lack of introductory context may make it difficult to understand for readers without a background in the field.
This comprehensive investigation is a useful stepping stone for adjusting policies based on real-life data, although more region-specific data is needed to unravel local differences.
Implications for practice
A few important implications for practice arise from this paper. Firstly, perceived need is the most important barrier to receiving treatment. Simultaneously, this is a complex challenge. Not recognising the need for care can be life-threatening in some disorders, but it is not necessarily problematic in all cases. If individuals do not view their condition as burdensome or feel like they need help for it, it raises ethical questions about who should determine the need for treatment. Furthermore, differences within disorder categories were found. For example, alcohol use disorder, the most prevalent substance use disorder, was associated with a significantly lower perceived need for care. This may suggest that there is still a degree of normalisation of some problematic behaviours that influence whether people think they need help. Although location is not mentioned in this finding, it is especially prevalent in Western countries to normalise drinking alcohol very often, which overlooks the detrimental effects of this. Therefore, enhancing awareness of when one needs care needs to be tailored per region, based on local differences of what is considered harmful behaviour.
Additionally, it is notable that the paper finds that access to general medical care (and not mental health care specifically) is predictive of receiving effective treatment. This suggests that strengthening general health care and access to it is of importance for those needing mental health care. This approach may also be strategic, especially in times of widespread mental health budget cuts and increasing mental health stigmatisation in some places. Thus, if primary care physicians are trained to detect mental health difficulties, this could greatly enhance the chance of receiving effective treatment for those needing it. Furthermore, the paper also reveals an important sex difference, with men being 50% less likely to receive effective treatment than women, while having double the rate of substance use disorders and suicide deaths. While we cannot establish the direction of these effects based on cross-sectional data, it definitely indicates that men need better access to mental health care. Targeting experienced stigma, shame, or unawareness of symptoms or resources may be feasible to reduce this disparity, and should not be overlooked in implementing mental health-focused policies.
The perceived need for care is an important component to increase access to effective treatment, but for policy purposes, it cannot be treated equally across disorders, cultural contexts, and requires careful ethical considerations.
Statement of interest
No conflicts of interest to declare with any of the authors in the paper.
Links
Primary paper
Vigo, D. V., Stein, D. J., Harris, M. G., Kazdin, A. E., Viana, M. C., Munthali, R., Munro, L., Hwang, I., Kessler, T. L., Manoukian, S. M., Sampson, N. A., Kessler, R. C., & World Mental Health Survey Collaborators (2025). Effective Treatment for Mental and Substance Use Disorders in 21 Countries. JAMA psychiatry, 82(4), 347–357.
