People with poor mental health have markedly different health profiles and health system experience, with lower patient activation, worse care quality, and lower confidence in the health system across 18 high-, middle-, and low-income countries.
Key Findings
Results
Prevalence of self-reported poor mental health varied widely across 18 countries and was unrelated to national income per capita.
Prevalence ranged from 4.7% in Nigeria to 39.6% in China.
Data were collected from 32,419 adults across 18 countries in 2022 and 2023.
Surveys used a combination of nationally representative telephone, online, and in-person methods.
The lack of correlation with national income per capita was a notable finding, challenging assumptions that mental health burden tracks with wealth.
Results
More women than men reported poor mental health in most of the 18 countries surveyed.
This gender disparity was observed across countries at different income levels.
The finding is based on self-reported mental health status rather than clinical diagnoses.
This pattern was consistent across the majority of the 18 countries included in the analysis.
Results
People with poor mental health had worse self-rated overall health and more chronic illness compared to those with good mental health.
This pattern was observed across all countries in the study.
The finding highlights the comorbidity burden among people with poor mental health.
Comparisons were made between adults with poor versus good mental health within each country.
These differences in health profile were consistent regardless of national income level.
Results
Receipt of mental healthcare in the past year among people with poor mental health varied enormously across countries.
The proportion of people with poor mental health who received mental healthcare ranged from 0.9% in Lao PDR to 52.4% in the UK.
This wide variation indicates substantial differences in access to and utilization of mental health services globally.
Even in the highest-access country (UK), nearly half of those with poor mental health had not received mental healthcare in the past year.
In low-access countries, the vast majority of people with poor mental health went without mental healthcare.
Results
People with poor mental health reported lower patient activation, worse care quality, and lower confidence in the health system across all countries.
These differences in health system experience were observed consistently across all 18 countries.
Lower patient activation suggests people with poor mental health are less engaged in managing their own health.
Worse care quality and lower system confidence indicate a systematically different and less satisfactory health system experience for this group.
Results are based on self-reported data rather than clinical assessments or administrative records.
Methods
The study used the People's Voice Survey, a cross-sectional dataset from 18 high-, middle-, and low-income countries collected in 2022 and 2023.
Total sample size was 32,419 adults.
Data collection methods included nationally representative telephone, online, and in-person surveys.
A key limitation is that mental health status was based on self-report rather than clinical diagnosis.
The cross-sectional design limits causal inference about health system experience and mental health status.
Conclusions
The authors conclude that health systems should re-assess their services to better serve people with poor mental health, and that cross-country benchmarking may assist in evaluating performance.
The findings are intended to prompt health policy action given the large and growing population with poor mental health.
The authors suggest that comparison of user experience and quality over time and across countries with similar health systems may assist in benchmarking performance.
Rates of depression and anxiety have risen substantially since the COVID pandemic, making poor mental health a top health policy priority in many countries.
What This Means
This research suggests that people who report poor mental health face a distinctly different and worse experience with healthcare systems compared to people who report good mental health. Analyzing survey data from over 32,000 adults across 18 countries collected in 2022 and 2023, the researchers found that people with poor mental health were less engaged in their own care, rated their care quality lower, and had less confidence in health systems overall — and this pattern held across wealthy, middle-income, and lower-income countries alike. Strikingly, how common poor mental health was had nothing to do with how rich a country was, ranging from under 5% in Nigeria to nearly 40% in China.
The study also found that most people with poor mental health are not receiving any mental healthcare. In some countries, fewer than 1 in 100 people with poor mental health had received mental health treatment in the past year, and even in the UK — which had the highest rate — nearly half of those with poor mental health had gone without mental healthcare. Women were more likely than men to report poor mental health in most countries studied. People with poor mental health also tended to have worse overall physical health and more chronic illnesses, pointing to a high burden of combined health needs.
This research matters because it provides rare cross-national data showing that people with poor mental health are a large, growing, and underserved group with distinct needs that health systems are currently not meeting well. The findings suggest that simply expanding mental health services may not be enough — health systems may need to fundamentally rethink how they organize and deliver care to reach and effectively serve people struggling with mental health. The ability to compare countries may help policymakers identify what approaches work best.
Kruk M, Kapoor N, Arsenault C, Carai S, Daray F, Doubova S, et al.. (2026). Health system use and experience among people with poor mental health: A cross-sectional analysis of the People's Voice Survey in 18 countries.. PLoS medicine. https://doi.org/10.1371/journal.pmed.1004745