Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report
Authors: Stein Dan J. , Kazdin Alan E. , Ruscio Ayelet Meron , Chiu Wai Tat , Sampson Nancy A. , Ziobrowski Hannah N. , Aguilar-Gaxiola Sergio , Al-Hamzawi Ali , Alonso Jordi , Altwaijri Yasmin , Bruffaerts Ronny , Bunting Brendan , de Girolamo Giovanni , de Jonge Peter , Degenhardt Louisa , Gureje Oye , Haro Josep Maria , Harris Meredith G. , Karam Aimee , Karam Elie G. , Kovess-Masfety Viviane , Lee Sing , Medina-Mora Maria Elena , Moskalewicz Jacek , Navarro-Mateu Fernando , Nishi Daisuke , Posada-Villa José , Scott Kate M. , Viana Maria Carmen , Vigo Daniel V. , Xavier Miguel , Zarkov Zahari , Kessler Ronald C. ,   on behalf of the WHO World Mental Health Survey collaborators, Aguilar-Gaxiola Sergio , Al-Hamzawi Ali , Al-Kaisy Mohammed Salih , Alonso Jordi , Altwaijri Yasmin A. , Andrade Laura Helena , Atwoli Lukoye , Benjet Corina , Borges Guilherme , Bromet Evelyn J. , Bruffaerts Ronny , Bunting Brendan , Caldas-de-Almeida Jose Miguel , Cardoso Graça , Chatterji Somnath , Cia Alfredo H. , Degenhardt Louisa , Demyttenaere Koen , Florescu Silvia , de Girolamo Giovanni , Gureje Oye , Haro Josep Maria , Harris Meredith G. , Hinkov Hristo , Hu Chi-yi , de Jonge Peter , Karam Aimee Nasser , Karam Elie G. , Kawakami Norito , Kessler Ronald C. , Kiejna Andrzej , Kovess-Masfety Viviane , Lee Sing , Lepine Jean-Pierre , McGrath John J. , Medina-Mora Maria Elena , Mneimneh Zeina , Moskalewicz Jacek , Navarro-Mateu Fernando , Piazza Marina , Posada-Villa Jose , Scott Kate M. , Slade Tim , Stagnaro Juan Carlos , Stein Dan J. , ten Have Margreet , Torres Yolanda , Viana Maria Carmen , Vigo Daniel V. , Whiteford Harvey , Williams David R. , Wojtyniak Bogdan 
Published: August 2021

Abstract
Background
Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment.

Methods
Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment.

Results
The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness.

Conclusions
The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.