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Importance The perceived helpfulness of treatment is an important patient-centered measure that is a joint function of whether treatment professionals are perceived as helpful and whether patients persist in help-seeking after previous unhelpful treatments. Objective To examine the prevalence and factors associated with the 2 main components of perceived helpfulness of treatment in a representative sample of individuals with a lifetime history ofDSM-IVmajor depressive disorder (MDD). Design, Setting, and Participants This study examined the results of a coordinated series of community epidemiologic surveys of noninstitutionalized adults using the World Health Organization World Mental Health surveys. Seventeen surveys were conducted in 16 countries (8 surveys in high-income countries and 9 in low- and middle-income countries). The dates of data collection ranged from 2002 to 2003 (Lebanon) to 2016 to 2017 (Bulgaria). Participants included those with a lifetime history of treated MDD. Data analyses were conducted from April 2019 to January 2020. Data on socioeconomic characteristics, lifetime comorbid conditions (eg, anxiety and substance use disorders), treatment type, treatment timing, and country income level were collected. Main Outcomes and Measures Conditional probabilities of helpful treatment after seeing between 1 and 5 professionals; persistence in help-seeking after between 1 and 4 unhelpful treatments; and ever obtaining helpful treatment regardless of number of professionals seen. Results Survey response rates ranged from 50.4% (Poland) to 97.2% (Medellin, Columbia), with a pooled response rate of 68.3% (n = 117 616) across surveys. Mean (SE) age at first depression treatment was 34.8 (0.3) years, and 69.4% were female. Of 2726 people with a lifetime history of treatment of MDD, the cumulative probability (SE) of all respondents pooled across countries of helpful treatment after seeing up to 10 professionals was 93.9% (1.2%), but only 21.5% (3.2%) of patients persisted that long (ie, beyond 9 unhelpful treatments), resulting in 68.2% (1.1%) of patients ever receiving treatment that they perceived as helpful. The probability of perceiving treatment as helpful increased in association with 4 factors: older age at initiating treatment (adjusted odds ratio [AOR], 1.02; 95% CI, 1.01-1.03), higher educational level (low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level), shorter delay in initiating treatment after first onset (AOR, 0.98; 95% CI, 0.97-0.99), and medication received from a mental health specialist (AOR, 2.91; 95% CI, 2.04-4.15). Decomposition analysis showed that the first 2 of these 4 factors were associated with only the conditional probability of an individual treatment professional being perceived as helpful (age at first depression treatment: AOR, 1.02; 95% CI, 1.01-1.02; educational level: low: AOR, 0.48; 95% CI, 0.33-0.70; low-average: AOR, 0.62; 95% CI, 0.44-0.89; high-average: AOR, 0.67; 95% CI, 0.49-0.91 vs high educational level), whereas the latter 2 factors were associated with only persistence (treatment delay: AOR, 0.98; 95% CI, 0.97-0.99; treatment type: AOR, 3.43; 95% CI, 2.51-4.70). Conclusions and Relevance The probability that patients with MDD obtain treatment that they consider helpful might increase, perhaps markedly, if they persisted in help-seeking after unhelpful treatments with up to 9 prior professionals.

IMPORTANCE: Generalized anxiety disorder (GAD) is poorly understood compared with other anxiety disorders, and debates persist about the seriousness of this disorder. Few data exist on GAD outside a small number of affluent, industrialized nations. No population-based data exist on GAD as it is currently defined in DSM-5. OBJECTIVE: To provide the first epidemiologic data on DSM-5 GAD and explore cross-national differences in its prevalence, course, correlates, and impact. DESIGN, SETTING, AND PARTICIPANTS: Data come from the World Health Organization World Mental Health Survey Initiative. Cross-sectional general population surveys were carried out in 26 countries using a consistent research protocol and assessment instrument. A total of 147 261 adults from representative household samples were interviewed face-to-face in the community. The surveys were conducted between 2001 and 2012. Data analysis was performed from July 22, 2015, to December 12, 2016. MAIN OUTCOMES AND MEASURES: The Composite International Diagnostic Interview was used to assess GAD along with comorbid disorders, role impairment, and help seeking. RESULTS: Respondents were 147 261 adults aged 18 to 99 years. The surveys had a weighted mean response rate of 69.5%. Across surveys, DSM-5 GAD had a combined lifetime prevalence (SE) of 3.7% (0.1%), 12-month prevalence of 1.8% (0.1%), and 30-day prevalence of 0.8% (0). Prevalence estimates varied widely across countries, with lifetime prevalence highest in high-income countries (5.0% [0.1%]), lower in middle-income countries (2.8% [0.1%]), and lowest in low-income countries (1.6% [0.1%]). Generalized anxiety disorder typically begins in adulthood and persists over time, although onset is later and clinical course is more persistent in lower-income countries. Lifetime comorbidity is high (81.9% [0.7%]), particularly with mood (63.0% [0.9%]) and other anxiety (51.7% [0.9%]) disorders. Severe role impairment is common across life domains (50.6% [1.2%]), particularly in high-income countries. Treatment is sought by approximately half of affected individuals (49.2% [1.2%]), especially those with severe role impairment (59.4% [1.8%]) or comorbid disorders (55.8% [1.4%]) and those living in high-income countries (59.0% [1.3%]). CONCLUSIONS AND RELEVANCE: The findings of this study show that DSM-5 GAD is more prevalent than DSM-IV GAD and is associated with substantial role impairment. The disorder is especially common and impairing in high-income countries despite a negative association between GAD and socioeconomic status within countries. These results underscore the public health significance of GAD across the globe while uncovering cross-national differences in prevalence, course, and impairment that require further investigation. The WHO WMH Survey Initiative is supported by National Institute of Mental Health (NIMH) grant R01 MH070884; the John D. and Catherine T. MacArthur Foundation; the Pfizer Foundation; US Public Health Service grants R13-MH066849, R01-MH069864, and R01 DA016558; Fogarty International Center grant FIRCA R03-TW006481; the Pan American Health Organization; Eli Lilly and Company; Ortho-McNeil Pharmaceutical, Inc; GlaxoSmithKline; and Bristol-Myers Squibb. 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 Thematic Project grant 03/00204-3. The Bulgarian Epidemiological Study of common mental disorders Epidemiology and Bulgaria is supported by the Ministry of Health and the National Center for Public Health Protection. The Chinese WMH Survey Initiative is supported by the Pfizer Foundation. The Shenzhen Mental Health Survey is supported by the Shenzhen Bureau of Health and the Shenzhen Bureau of Science, Technology, and Information. The Colombian National Study of Mental Health 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 European Study of the Epidemiology of Mental Disorders project is funded by 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 grant FIS 00/0028; Ministerio de Ciencia y Tecnología, Spain, grant SAF 2000-158-CE; Departament de Salut, Generalitat de Catalunya, Spain; Instituto de Salud Carlos III grants CIBER CB06/02/0046 and 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 Ministry of Health and Ministry of Planning 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. The Israel National Health Survey is funded by the Ministry of Health with support from the Israel National Institute for Health Policy and Health Services Research and the National Insurance Institute of Israel. The WMH Japan Survey is supported by grants H13-SHOGAI-023, H14-TOKUBETSU-026, and H16-KOKORO-013 for Research on Psychiatric and Neurological Diseases and Mental Health from the Japan Ministry of Health, Labour and Welfare. The Lebanese Evaluation of the Burden of Ailments and Needs of the Nation is supported by the Lebanese Ministry of Public Health, the WHO (Lebanon), National Institute of Health/Fogarty International Center grant R03 TW006481-01, anonymous private donations to Institute for Development Research Advocacy and Applied Care, Lebanon, and unrestricted grants from Algorithm, AstraZeneca, Benta, Bella Pharma, Eli Lilly, GlaxoSmithKline, Lundbeck, Novartis, Servier, Phenicia, and Union Pharmaceutique d'Orient SAL. The Mexican National Comorbidity Survey is supported by The National Institute of Psychiatry Ramon de la Fuente grant INPRFMDIES 4280 and by the National Council on Science and Technology grant CONACyT-G30544-H, with supplemental support from the Pan American Health Organization. Te Rau Hinengaro: The New Zealand Mental Health Survey is supported by the New Zealand Ministry of Health, Alcohol Advisory Council, and the Health Research Council. The Nigerian Survey of Mental Health and Wellbeing is supported by the WHO (Geneva), the WHO (Nigeria), and the Federal Ministry of Health, Abuja, Nigeria. The Northern Ireland Study of Mental Health was funded by the Health & Social Care Research & Development Division of the Public Health Agency. The Peruvian WMH 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 grant PL 0256 was supported by Iceland, Liechtenstein, and Norway through funding from the European Economic Area Financial Mechanism and the Norwegian Financial Mechanism; the EZOP Project was cofinanced 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 and Ministry of Health. The Romania WMH Survey Initiative study projects Policies in Mental Health Area and National Study Regarding Mental Health and Services Use were carried out by the National School of Public Health & Health Services Management (formerly the 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, Societatea Comerciala Cheyenne Services SRL, and Statistics Netherlands and were funded by the Ministry of Public Health (formerly the Ministry of Health) with supplemental support from Eli Lilly Romania SRL. The South Africa Stress and Health Study is supported by US NIMH grant R01-MH059575 and the National Institute of Drug Abuse, with supplemental funding from the South African Department of Health and the University of Michigan. The Psychiatric Enquiry to General Population in Southeast Spain–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 of Murcia. The Ukraine Comorbid Mental Disorders During Periods of Social Disruption study is funded by US NIMH grant R01-MH61905. The US National Comorbidity Survey Replication is supported by NIMH grant U01-MH60220 with supplemental support from the National Institute of Drug Abuse, the Substance Abuse and Mental Health Services Administration, Robert Wood Johnson Foundation grant 044708, and the John W. Alden Trust. Preparation of this manuscript was supported by grant R01 MH094425 from the NIMH (Dr Ruscio).

IMPORTANCE: Community-based surveys find that many otherwise healthy individuals report histories of hallucinations and delusions. To date, most studies have focused on the overall lifetime prevalence of any of these psychotic experiences (PEs), which might mask important features related to the types and frequencies of PEs. OBJECTIVE: To explore detailed epidemiologic information about PEs in a large multinational sample./nDESIGN, SETTING, AND PARTICIPANTS: We obtained data from the World Health Organization World Mental Health Surveys, a coordinated set of community epidemiologic surveys of the prevalence and correlates of mental disorders in representative household samples from 18 countries throughout the world, from 2001 through 2009. Respondents included 31,261 adults (18 years and older) who were asked about lifetime and 12-month prevalence and frequency of 6 types of PEs (2 hallucinatory experiences and 4 delusional experiences). We analyzed the data from March 2014 through January 2015. MAIN OUTCOMES AND MEASURES: Prevalence, frequency, and correlates of PEs. RESULTS: Mean lifetime prevalence (SE) of ever having a PE was 5.8% (0.2%), with hallucinatory experiences (5.2% [0.2%]) much more common than delusional experiences (1.3% [0.1%]). More than two-thirds (72.0%) of respondents with lifetime PEs reported experiencing only 1 type. Psychotic experiences were typically infrequent, with 32.2% of respondents with lifetime PEs reporting only 1 occurrence and 31.8% reporting only 2 to 5 occurrences. We found a significant relationship between having more than 1 type of PE and having more frequent PE episodes (Cochran-Armitage z = -10.0; P

IMPORTANCE: It is clear that mental disorders in treatment settings are associated with a higher incidence of chronic physical conditions, but whether this is true of mental disorders in the community, and how generalized (across a range of physical health outcomes) these associations are, is less clear. This information has important implications for mental health care and the primary prevention of chronic physical disease. OBJECTIVE: To investigate associations of 16 temporally prior DSM-IV mental disorders with the subsequent onset or diagnosis of 10 chronic physical conditions. DESIGN, SETTING, AND PARTICIPANTS: Eighteen face-to-face, cross-sectional household surveys of community-dwelling adults were conducted in 17 countries (47 609 individuals; 2 032 942 person-years) from January 1, 2001, to December 31, 2011. The Composite International Diagnostic Interview was used to retrospectively assess the lifetime prevalence and age at onset of DSM-IV-identified mental disorders. Data analysis was performed from January 3, 2012, to September 30, 2015. MAIN OUTCOMES AND MEASURES: Lifetime history of physical conditions was ascertained via self-report of physician's diagnosis and year of onset or diagnosis. Survival analyses estimated the associations of temporally prior first onset of mental disorders with subsequent onset or diagnosis of physical conditions. RESULTS: Most associations between 16 mental disorders and subsequent onset or diagnosis of 10 physical conditions were statistically significant, with odds ratios (ORs) (95% CIs) ranging from 1.2 (1.0-1.5) to 3.6 (2.0-6.6). The associations were attenuated after adjustment for mental disorder comorbidity, but mood, anxiety, substance use, and impulse control disorders remained significantly associated with onset of between 7 and all 10 of the physical conditions (ORs [95% CIs] from 1.2 [1.1-1.3] to 2.0 [1.4-2.8]). An increasing number of mental disorders experienced over the life course was significantly associated with increasing odds of onset or diagnosis of all 10 types of physical conditions, with ORs (95% CIs) for 1 mental disorder ranging from 1.3 (1.1-1.6) to 1.8 (1.4-2.2) and ORs (95% CIs) for 5 or more mental disorders ranging from 1.9 (1.4-2.7) to 4.0 (2.5-6.5). In population-attributable risk estimates, specific mental disorders were associated with 1.5% to 13.3% of physical condition onsets. CONCLUSIONS AND RELEVANCE: These findings suggest that mental disorders of all kinds are associated with an increased risk of onset of a wide range of chronic physical conditions. Current efforts to improve the physical health of individuals with mental disorders may be too narrowly focused on the small group with the most severe mental disorders. Interventions aimed at the primary prevention of chronic physical diseases should optimally be integrated into treatment of all mental disorders in primary and secondary care from early in the disorder course. The World Health Organization World Mental Health (WMH) Survey Initiative is supported by the National Institute of Mental Health (NIMH; R01 MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly & Company, Ortho-McNeil Pharmaceutical,GlaxoSmithKline, and Bristol-Myers Squibb. The Colombian National Study of Mental Health was supported by the Ministry of Social Protection, with supplemental support from the Saldarriaga Concha Foundation. The European surveys were funded by the European Commission (Contracts QLG5-1999-01042, SANCO 2004123, and EAH 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), Departament de Salut, Generalitat de Catalunya, Spain, 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. The WMH Japan Survey was supported by the Grant for Research on Psychiatric and Neurological Diseases and Mental Health (H13-SHOGAI-023, H14-TOKUBETSU-026, and H16-KOKORO-013) from the Japan Ministry of Health, Labour, and Welfare. The Mexican National Comorbidity Survey was 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. The Peruvian WMH 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 Poland was funded by the Norwegian Financial Mechanism and the European Economic Area Mechanism as well as the Polish Ministry of Health. No support from pharmaceutical industry or other commercial sources was received. The Shenzhen Mental Health Survey was supported by the Shenzhen Bureau of Health and the Shenzhen Bureau of Science, Technology, and Information. The Iraq Mental Health Survey received funding from both the Japanese and European Funds through United Nations Development Group Iraq Trust Fund. The Israel National Health Survey was funded by the Ministry of Health with support from the Israel National Institute for Health Policy and Health Services Research and the National Insurance Institute of Israel. Te Rau Hinengaro: The New Zealand Mental Health Survey was supported by the New Zealand Ministry of Health, Alcohol Advisory Council, and Health Research Council. The Portuguese Mental Health Study was funded by the Champalimaud Foundation, Gulbenkian Foundation, Foundation for Science and Technology, and Ministry of Health. The Romania WMH study projects—Policies in Mental Health Area and National Study Regarding Mental Health and Services Use—were funded by the Ministry of Public Health (former Ministry of Health), with supplemental support of Eli Lilly Romania SRL. The US National Comorbidity Survey Replication is supported by the NIMH (U01-MH60220), with supplemental support from the National Institute of Drug Abuse, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation (grant 044708), and the John W. Alden Trust. Work on this article was partially funded by grant 11/200 from the Health Research Council of New Zealand (Dr Scott)