Determinants of access to health care for depression in 49 countries: A multilevel analysis.

01 Jul 2018
Araya R, Zitko P, Markkula N, Rai D, Jones K


The relative importance of individual and country-level factors influencing access to diagnosis and treatment for depression across the world is fairly unknown.


We analysed cross-national data from the WHO World Health Surveys. Depression diagnosis and access to health care were ascertained using a structured interview. Logistic Bayesian Multilevel analyses were performed to establish individual and country level factors associated with: (1) receiving a diagnosis and (2) accessing treatment for depression if a diagnosis was ascertained.


The sample included 7870 individuals from 49 countries who met ICD-10 criteria for depressive episode in the past 12 months. A third (32%) of these individuals had ever been diagnosed with depression in their lifetime. Among those diagnosed with depression, 66% reported to have ever received treatment for depression. Although individual factors were more important determinants of access to treatment for depression, country-level factors explained 27.6% of the variance in access to diagnosis and 24.1% in access to treatment. Access to treatment for depression improved with increasing country income. Female gender, better education, the presence of physical co-morbidity, more material assets, and living in urban areas were individual level determinants of better access.


Data on other contextual factors was not available. Unmet need was likely underestimated, since only lifetime treatment data was available.


This study highlights major inequalities in access to a diagnosis and treatment of depression. Unlike the prevalence of depression, where contextual factors have shown to have less importance, a significant proportion of the variance in access to depression care was explained by country-level income.