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

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

Strengthening quality of care through standardized reporting based on the World Health Organization's reference classifications.

QUALITY ISSUE: Responding to person's health and related needs requires the availability of health information that reflects relevant aspects of a health condition and how this health condition impacts on a person's daily life. INITIAL ASSESSMENT: Health information is routinely collected at different time points by diverse professionals, in different settings for various purposes with varying methods. Consequently, health information is not always comparable, posing a challenge to the regular monitoring of quality. CHOICE OF SOLUTION: The World Health Organization's (WHO) International Classification of Diseases (ICD), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI; under development) are complementary and serve as meaningful reference classifications for comparing data on persons' health and related interventions across health systems. IMPLEMENTATION: We developed a systematic approach of translating routinely collected information into a standardized report based on the three WHO reference classifications and the Rehab-Cycle®. Subsequently, we have demonstrated its application using five random case records of individuals attending a rehabilitation program. EVALUATION: All identified concepts were able to be linked to WHO's reference classifications. The ICF served as a tool to standardize information on rehabilitation goals and their achievement. The ICHI served as the basis for reporting the interventions that were documented in the case records, including the intervention targets that were derived from the ICF codes. LESSONS LEARNED: Our experience shows that, it is possible to translate routinely collected information into standardized reports by linking existing narrative records with WHO's reference classifications.

Capturing patients' needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems.

BACKGROUND: Contemporary casemix systems for health services need to ensure that payment rates adequately account for actual resource consumption based on patients' needs for services. It has been argued that functioning information, as one important determinant of health service provision and resource use, should be taken into account when developing casemix systems. However, there has to date been little systematic collation of the evidence on the extent to which the addition of functioning information into existing casemix systems adds value to those systems with regard to the predictive power and resource variation explained by the groupings of these systems. Thus, the objective of this research was to examine the value of adding functioning information into casemix systems with respect to the prediction of resource use as measured by costs and length of stay. METHODS: A systematic literature review was performed. Peer-reviewed studies, published before May 2014 were retrieved from CINAHL, EconLit, Embase, JSTOR, PubMed and Sociological Abstracts using keywords related to functioning ('Functioning', 'Functional status', 'Function*, 'ICF', 'International Classification of Functioning, Disability and Health', 'Activities of Daily Living' or 'ADL') and casemix systems ('Casemix', 'case mix', 'Diagnosis Related Groups', 'Function Related Groups', 'Resource Utilization Groups' or 'AN-SNAP'). In addition, a hand search of reference lists of included articles was conducted. Information about study aims, design, country, setting, methods, outcome variables, study results, and information regarding the authors' discussion of results, study limitations and implications was extracted. RESULTS: Ten included studies provided evidence demonstrating that adding functioning information into casemix systems improves predictive ability and fosters homogeneity in casemix groups with regard to costs and length of stay. Collection and integration of functioning information varied across studies. Results suggest that, in particular, DRG casemix systems can be improved in predicting resource use and capturing outcomes for frail elderly or severely functioning-impaired patients. CONCLUSION: Further exploration of the value of adding functioning information into casemix systems is one promising approach to improve casemix systems ability to adequately capture the differences in patient's needs for services and to better predict resource use.

Mapping the content of the Patient-Reported Outcomes Measurement Information System (PROMIS®) using the International Classification of Functioning, Health and Disability.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS (®) ) is a US National Institutes of Health initiative that has produced self-reported item banks for physical, mental and social health. OBJECTIVE: To describe the content of PROMIS at the item level using the World Health Organization's International Classification of Functioning, Disability and Health (ICF). METHODS: All PROMIS adult items (publicly available as of 2012) were assigned to relevant ICF concepts. The content of the PROMIS adult item banks was then described using the mapped ICF code descriptors. RESULTS: The 1,006 items in the PROMIS instruments could all be mapped to ICF concepts at the second level of classification, with the exception of three items of global or general health that mapped across the first-level classification of ICF activity and participation component (d categories). Individual PROMIS item banks mapped from 1 to 5 separate ICF codes indicating one-to-one, one-to-many and many-to-one mappings between PROMIS item banks and ICF second-level classification codes. PROMIS supports measurement of the majority of major concepts in the ICF body functions (b) and activity and participation (d) components using PROMIS item banks or subsets of PROMIS items that could, with care, be used to develop customized instruments. Given that the focus of PROMIS is on measurement of person health outcomes, concepts in body structures (s) and some body functions (b), as well as many ICF environmental factor, have minimal coverage in PROMIS. DISCUSSION: The PROMIS-ICF mapped items provide a basis for users to evaluate the ICF-related content of specific PROMIS instruments and to select PROMIS instruments in ICF-based measurement applications.

Concept analysis of the patient reported outcomes measurement information system (PROMIS(®)) and the international classification of functioning, disability and health (ICF).

PURPOSE: The Patient Reported Outcomes Measurement Information System (PROMIS (®) ) is a US National Institutes of Health initiative that has produced self-report outcome measures, using a framework of physical, mental, and social health defined by the World Health Organization in 1948 (WHO, in Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 1948). The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is a comprehensive classification system of health and health-related domains that was put forward in 2001. The purpose of this report is to compare and contrast PROMIS and ICF conceptual frameworks to support mapping of PROMIS instruments to the ICF classification system . METHODS: We assessed the objectives and the classification schema of the PROMIS and ICF frameworks, followed by content analysis to determine whether PROMIS domain and sub-domain level health concepts can be linked to the ICF classification. RESULTS: Both PROMIS and ICF are relevant to all individuals, irrespective of the presence of health conditions, person characteristics, or environmental factors in which persons live. PROMIS measures are intended to assess a person's experiences of his or her health, functional status, and well-being in multiple domains across physical, mental, and social dimensions. The ICF comprehensively describes human functioning from a biological, individual, and social perspective. The ICF supports classification of health and health-related states such as functioning, but is not a specific measure or assessment of health, per se. PROMIS domains and sub-domain concepts can be meaningfully mapped to ICF concepts. CONCLUSIONS: Theoretical and conceptual similarities support the use of PROMIS instruments to operationalize self-reported measurement for many body function, activity and participation ICF concepts, as well as several environmental factor concepts. Differences observed in PROMIS and ICF conceptual frameworks provide a stimulus for future research and development.

The association of PTSD with physical and mental health functioning and disability (VA Cooperative Study #569: the course and consequences of posttraumatic stress disorder in Vietnam-era veteran twins).

PURPOSE: To assess the relationship of posttraumatic stress disorder (PTSD) with health functioning and disability in Vietnam-era Veterans. METHODS: A cross-sectional study of functioning and disability in male Vietnam-era Veteran twins. PTSD was measured by the Composite International Diagnostic Interview; health functioning and disability were assessed using the Veterans RAND 36-Item Health Survey (VR-36) and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). All data collection took place between 2010 and 2012. RESULTS: Average age of the 5,574 participating Veterans (2,102 Vietnam theater and 3,472 non-theater) was 61.0 years. Veterans with PTSD had poorer health functioning across all domains of VR-36 and increased disability for all subscales of WHODAS 2.0 (all p < .001) compared with Veterans without PTSD. Veterans with PTSD were in poorer overall health on the VR-36 physical composite summary (PCS) (effect size = 0.31 in theater and 0.47 in non-theater Veterans; p < .001 for both) and mental composite summary (MCS) (effect size = 0.99 in theater and 0.78 in non-theater Veterans; p < .001 for both) and had increased disability on the WHODAS 2.0 summary score (effect size = 1.02 in theater and 0.96 in non-theater Veterans; p < .001 for both). Combat exposure, independent of PTSD status, was associated with lower PCS and MCS scores and increased disability (all p < .05, for trend). Within-pair analyses in twins discordant for PTSD produced consistent findings. CONCLUSIONS: Vietnam-era Veterans with PTSD have diminished functioning and increased disability. The poor functional status of aging combat-exposed Veterans is of particular concern.

ICD-11 for quality and safety: overview of the WHO Quality and Safety Topic Advisory Group.

This paper outlines the approach that the WHO's Family of International Classifications (WHO-FIC) network is undertaking to create ICD-11. We also outline the more focused work of the Quality and Safety Topic Advisory Group, whose activities include the following: (i) cataloguing existing ICD-9 and ICD-10 quality and safety indicators; (ii) reviewing ICD morbidity coding rules for main condition, diagnosis timing, numbers of diagnosis fields and diagnosis clustering; (iii) substantial restructuring of the health-care related injury concepts coded in the ICD-10 chapters 19/20, (iv) mapping of ICD-11 quality and safety concepts to the information model of the WHO's International Classification for Patient Safety and the AHRQ Common Formats; (v) the review of vertical chapter content in all chapters of the ICD-11 beta version and (vi) downstream field testing of ICD-11 prior to its official 2015 release. The transition from ICD-10 to ICD-11 promises to produce an enhanced classification that will have better potential to capture important concepts relevant to measuring health system safety and quality-an important use case for the classification.

Counting disability: global and national estimation.

PURPOSE: How many people with disabilities are in the world? How is disability defined? How can we measure disability in an accurate and comparable way? These are some of the key questions which the recently published World Bank/WHO World Report on Disability (WRD) addresses. METHOD: Multiple data sources and methods were used by WHO and the World Bank to estimate a global figure, with the ICF as the underlying data standard. Key international data sources were the World Health Survey of 2002-2004 and the 2004 updates from the Global Burden of Disease study. The World Report on Disability also includes a compilation of country-reported prevalence from census and surveys. This paper presents and discusses key findings of the Irish National Disability Survey (2006) to illustrate the value of the ICF framework for disability statistics and most especially the environmental factors component. RESULTS: The World Report estimates that globally one billion people or 15% of the world's population experience disabilities. Between 110-190 million people (2% of the world's population) experience severe or extreme difficulties in functioning. Definitions and measures of disability vary widely across countries. The Irish Disability Survey shows the substantial impact of environmental factors on people's functioning. For example, attitudes, and the presence or absence of facilitating equipment, support services, flexible working arrangements and transport significantly affect participation of people with disabilities in Irish society. CONCLUSIONS: To improve the quality of disability information, the World Report recommends the use of a common definition and concepts of disability based on WHO's International Classification of Functioning Disability and Health (ICF). Furthermore, disability measurement needs to apply a multidimensional approach, in particular, measuring disability in terms of the level of difficulty a person is experiencing in multiple areas of life, rather than head counting severe impairment types in a dichotomous way. Environmental factors have significant effects on individual functioning and should be considered as an integral part in disability measurement.

Development of lifetime comorbidity in the World Health Organization world mental health surveys.

CONTEXT: Although numerous studies have examined the role of latent variables in the structure of comorbidity among mental disorders, none has examined their role in the development of comorbidity. OBJECTIVE: To study the role of latent variables in the development of comorbidity among 18 lifetime DSM-IV disorders in the World Health Organization World Mental Health Surveys. DESIGN: Nationally or regionally representative community surveys. SETTING: Fourteen countries. PARTICIPANTS: A total of 21 229 survey respondents. MAIN OUTCOME MEASURES: First onset of 18 lifetime DSM-IV anxiety, mood, behavior, and substance disorders assessed retrospectively in the World Health Organization Composite International Diagnostic Interview. RESULTS: Separate internalizing (anxiety and mood disorders) and externalizing (behavior and substance disorders) factors were found in exploratory factor analysis of lifetime disorders. Consistently significant positive time-lagged associations were found in survival analyses for virtually all temporally primary lifetime disorders predicting subsequent onset of other disorders. Within-domain (ie, internalizing or externalizing) associations were generally stronger than between-domain associations. Most time-lagged associations were explained by a model that assumed the existence of mediating latent internalizing and externalizing variables. Specific phobia and obsessive-compulsive disorder (internalizing) and hyperactivity and oppositional defiant disorders (externalizing) were the most important predictors. A small number of residual associations remained significant after controlling the latent variables. CONCLUSIONS: The good fit of the latent variable model suggests that common causal pathways account for most of the comorbidity among the disorders considered herein. These common pathways should be the focus of future research on the development of comorbidity, although several important pairwise associations that cannot be accounted for by latent variables also exist that warrant further focused study.

Assessing the impact of musculoskeletal health conditions using the International Classification of Functioning, Disability and Health.

PURPOSE: To propose the joint use of the International Classification of Diseases (ICD) and the International Classification of Functioning, Disability and Health (ICF) and to illustrate this proposal using musculoskeletal (MSK) conditions. METHOD: In light of the MSK conditions as classified in the ICD, categories from existing ICF core sets for MSK conditions were pooled to specify functioning. Another approach was to consider other categories from measures or instruments already linked in the literature. RESULTS: ICF Categories have been pooled from six core sets for MSK conditions, two specific care settings, one MSK clinical trial setting and eight instrument linkage papers. CONCLUSIONS: The ICD-ICF joint use would be able to capture the impact of a health condition by taking into account the disease and functioning status which would facilitate clinical care. Therefore, there is reasonable ground to demonstrate the operational linkage and complementary role of the ICD and the ICF in the context of the ICD revision.

Assessing the impact of health conditions using the ICF.

PURPOSE: People may suffer from diseases and a variety of health conditions, but a full understanding of the experience of their health condition also requires comprehensive information about the impact of the disease or the health condition on the person. This article operationalises the impacts of health conditions as classified in the International Classification of Diseases (ICD) in terms of the concept of functioning as found in the International Classification of Functioning, Disability and Health (ICF). It identifies a set of ICF categories as the functioning properties - to describe the impact of health conditions generically across health conditions to be jointly used with the ICD. METHOD: The ICF categories to characterise the functioning properties of any health condition have been selected from three main generic health profile instruments: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), the World Health Survey (WHS) Questionnaire and a list of candidate categories of the generic ICF core set. RESULTS: A set of ICF categories to describe the impact of a health condition is presented according to specific functioning domains. CONCLUSIONS: The joint use of the ICD and the ICF through the list of functioning properties and in the context of ICD-11 development captures the valuable synergy of the two classifications. It enhances patient management, intervention design and the reporting of health. It also enables us to distinguish severity of disease from its impacts. The ICD-ICF joint use creates a shared formal representation across the continuum of care for health information system implementation.

Days out of role due to common physical and mental conditions: results from the WHO World Mental Health surveys.

Days out of role because of health problems are a major source of lost human capital. We examined the relative importance of commonly occurring physical and mental disorders in accounting for days out of role in 24 countries that participated in the World Health Organization (WHO) World Mental Health (WMH) surveys. Face-to-face interviews were carried out with 62 971 respondents (72.0% pooled response rate). Presence of ten chronic physical disorders and nine mental disorders was assessed for each respondent along with information about the number of days in the past month each respondent reported being totally unable to work or carry out their other normal daily activities because of problems with either physical or mental health. Multiple regression analysis was used to estimate associations of specific conditions and comorbidities with days out of role, controlling by basic socio-demographics (age, gender, employment status and country). Overall, 12.8% of respondents had some day totally out of role, with a median of 51.1 a year. The strongest individual-level effects (days out of role per year) were associated with neurological disorders (17.4), bipolar disorder (17.3) and post-traumatic stress disorder (15.2). The strongest population-level effect was associated with pain conditions, which accounted for 21.5% of all days out of role (population attributable risk proportion). The 19 conditions accounted for 62.2% of all days out of role. Common health conditions, including mental disorders, make up a large proportion of the number of days out of role across a wide range of countries and should be addressed to substantially increase overall productivity.

Including information about co-morbidity in estimates of disease burden: results from the World Health Organization World Mental Health Surveys.

BACKGROUND: The methodology commonly used to estimate disease burden, featuring ratings of severity of individual conditions, has been criticized for ignoring co-morbidity. A methodology that addresses this problem is proposed and illustrated here with data from the World Health Organization World Mental Health Surveys. Although the analysis is based on self-reports about one's own conditions in a community survey, the logic applies equally well to analysis of hypothetical vignettes describing co-morbid condition profiles. METHOD: Face-to-face interviews in 13 countries (six developing, nine developed; n=31 067; response rate=69.6%) assessed 10 classes of chronic physical and nine of mental conditions. A visual analog scale (VAS) was used to assess overall perceived health. Multiple regression analysis with interactions for co-morbidity was used to estimate associations of conditions with VAS. Simulation was used to estimate condition-specific effects. RESULTS: The best-fitting model included condition main effects and interactions of types by numbers of conditions. Neurological conditions, insomnia and major depression were rated most severe. Adjustment for co-morbidity reduced condition-specific estimates with substantial between-condition variation (0.24-0.70 ratios of condition-specific estimates with and without adjustment for co-morbidity). The societal-level burden rankings were quite different from the individual-level rankings, with the highest societal-level rankings associated with conditions having high prevalence rather than high individual-level severity. CONCLUSIONS: Plausible estimates of disorder-specific effects on VAS can be obtained using methods that adjust for co-morbidity. These adjustments substantially influence condition-specific ratings.

Developing the World Health Organization Disability Assessment Schedule 2.0.

OBJECTIVE: To describe the development of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for measuring functioning and disability in accordance with the International Classification of Functioning, Disability and Health. WHODAS 2.0 is a standard metric for ensuring scientific comparability across different populations. METHODS: A series of studies was carried out globally. Over 65,000 respondents drawn from the general population and from specific patient populations were interviewed by trained interviewers who applied the WHODAS 2.0 (with 36 items in its full version and 12 items in a shortened version). FINDINGS: The WHODAS 2.0 was found to have high internal consistency (Cronbach's alpha, α: 0.86), a stable factor structure; high test-retest reliability (intraclass correlation coefficient: 0.98); good concurrent validity in patient classification when compared with other recognized disability measurement instruments; conformity to Rasch scaling properties across populations, and good responsiveness (i.e. sensitivity to change). Effect sizes ranged from 0.44 to 1.38 for different health interventions targeting various health conditions. CONCLUSION: The WHODAS 2.0 meets the need for a robust instrument that can be easily administered to measure the impact of health conditions, monitor the effectiveness of interventions and estimate the burden of both mental and physical disorders across different populations.

Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys.

BACKGROUND: Although significant associations of childhood adversities with adult mental disorders are widely documented, most studies focus on single childhood adversities predicting single disorders. AIMS: To examine joint associations of 12 childhood adversities with first onset of 20 DSM-IV disorders in World Mental Health (WMH) Surveys in 21 countries. METHOD: Nationally or regionally representative surveys of 51 945 adults assessed childhood adversities and lifetime DSM-IV disorders with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Childhood adversities were highly prevalent and interrelated. Childhood adversities associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect) were the strongest predictors of disorders. Co-occurring childhood adversities associated with maladaptive family functioning had significant subadditive predictive associations and little specificity across disorders. Childhood adversities account for 29.8% of all disorders across countries. CONCLUSIONS: Childhood adversities have strong associations with all classes of disorders at all life-course stages in all groups of WMH countries. Long-term associations imply the existence of as-yet undetermined mediators.

The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys.

AIMS: The paper reviews recent findings from the WHO World Mental Health (WMH) surveys on the global burden of mental disorders. METHODS: The WMH surveys are representative community surveys in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, distribution, burden, and unmet need for treatment of common mental disorders. RESULTS: The first 17 WMH surveys show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25th-75th percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, externalizing, and substance use disorders) is 18.1-36.1%. The IQR of 12-month prevalence estimates is 9.8-19.1%. Prevalence estimates of 12-month Serious Mental Illness (SMI) are 4-6.8% in half the countries, 2.3-3.6% in one-fourth, and 0.8-1.9% in one-fourth. Many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions in the WMH data. Adult mental disorders are found to be associated with such high role impairment in the WMH data that available clinical interventions could have positive cost-effectiveness ratios. CONCLUSIONS: Mental disorders are commonly occurring and often seriously impairing in many countries throughout the world. Expansion of treatment could be cost-effective from both employer and societal perspectives.

Spectral-domain low coherence interferometry/optical coherence tomography system for fine needle breast biopsy guidance.

A novel technology and instrumentation for fine needle aspiration (FNA) breast biopsy guidance is presented. This technology is based on spectral-domain low coherence interferometry (SD-LCI). The method, apparatus, and preliminary in vitro/in vivo results proving the viability of the method and apparatus are presented in detail. An advanced tissue classification algorithm, preliminarily tested on breast tissue specimens and a mouse model of breast cancer is presented as well. Over 80% sensitivity and specificity in differentiating all tissue types and 93% accuracy in differentiating fatty tissue from fibrous or tumor tissue was obtained with this technology and apparatus. These results suggest that SD-LCI could help for more precise needle placement during the FNA biopsy and therefore could substantially reduce the number of the nondiagnostic aspirates and improve the sensitivity and specificity of the FNA procedures.

The WHO World Mental Health (WMH) Surveys.

The paper presents an overview of the WHO World Mental Health (WMH) Survey Initiative and summarizes recent WMH results regarding the prevalence and societal costs of mental disorders. The WMH surveys are representative community surveys that were carried out in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, burden, and unmet need for treatment of common mental disorders. Results show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25(th)-75(th) percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, disruptive behavior, and substance disorders) is 18.1-36.1%. The IQR of 12-month prevalence estimates is 9.8-19.1%. Analysis of age-of-onset reports shows that many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions. Adult mental disorders are found in the WMH data to be associated with high levels of role impairment. Despite this burden, the majority of mental disorders go untreated. Although these results suggest that expansion of treatment could be cost-effective from both the employer perspective and the societal perspective, treatment effectiveness trials are needed to confirm this suspicion. The WMH results regarding impairments are being used to target several such interventions.

Disability and treatment of specific mental and physical disorders across the world.

BACKGROUND: Advocates of expanded mental health treatment assert that mental disorders are as disabling as physical disorders, but little evidence supports this assertion. AIMS: To establish the disability and treatment of specific mental and physical disorders in high-income and low- and middle-income countries. METHOD: Community epidemiological surveys were administered in 15 countries through the World Health Organization World Mental Health (WMH) Survey Initiative. RESULTS: Respondents in both high-income and low- and middle-income countries attributed higher disability to mental disorders than to the commonly occurring physical disorders included in the surveys. This pattern held for all disorders and also for treated disorders. Disaggregation showed that the higher disability of mental than physical disorders was limited to disability in social and personal role functioning, whereas disability in productive role functioning was generally comparable for mental and physical disorders. CONCLUSIONS: Despite often higher disability, mental disorders are under-treated compared with physical disorders in both high-income and in low- and middle-income countries.