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The psychosis treatment gap and its consequences in rural Ethiopia

Fekadu, Abebaw; Medhin, Girmay; Lund, Crick; DeSilva, Mary; Selamu, Medhin; Alem, Atalay; Asher, Laura; Birhane, Rahel; Patel, Vikram; Hailemariam, Maji; Shibre, Teshome; Thornicroft, Graham; Prince, Martin; Hanlon, Charlotte


Abebaw Fekadu

Girmay Medhin

Crick Lund

Mary DeSilva

Medhin Selamu

Atalay Alem

Clinical Associate Professor

Rahel Birhane

Vikram Patel

Maji Hailemariam

Teshome Shibre

Graham Thornicroft

Martin Prince

Charlotte Hanlon


The “treatment gap” (TG) for mental disorders, widely advocated by the WHO in low-and middle-income countries, is an important indicator of the extent to which a health system fails to meet the care needs of people with mental disorder at the population level. While there is limited research on the TG in these countries, there is even a greater paucity of studies looking at TG beyond a unidimensional understanding. This study explores several dimensions of the TG construct for people with psychosis in Sodo, a rural district in Ethiopia, and its implications for building a more holistic capacity for mental health services.

The study was a cross-sectional survey of 300 adult participants with psychosis identified through community-based case detection and confirmed through subsequent structured clinical evaluations. The Butajira Treatment Gap Questionnaire (TGQ), a new customised tool with 83 items developed by the Ethiopia research team, was administered to evaluate several TG dimensions (access, adequacy and effectiveness of treatment, and impact/consequence of the treatment gap) across a range of provider types corresponding with the WHO pyramid service framework.

Lifetime and current access gap for biomedical care were 41.8 and 59.9% respectively while the corresponding figures for faith and traditional healing (FTH) were 15.1 and 45.2%. Of those who had received biomedical care for their current episode, 71.7% did not receive minimally adequate care. Support from the community and non-governmental organisations (NGOs) were negligible. Those with education (Adj. OR: 2.1; 95% CI: 1.2, 3.8) and history of use of FTH (Adj. OR: 3.2; 95% CI: 1.9–5.4) were more likely to use biomedical care. Inadequate biomedical care was associated with increased lifetime risk of adverse experiences, such as history of restraint, homelessness, accidents and assaults.

This is the first study of its kind. Viewing TG not as a unidimensional, but as a complex, multi-dimensional construct, offers a more realistic and holistic understanding of health beliefs, help-seeking behaviors, and need for care. The reconceptualized multidimensional TG construct could assist mental health services capacity building advocacy and policy efforts and allow community and NGOs play a larger role in supporting mental healthcare.


Fekadu, A., Medhin, G., Lund, C., DeSilva, M., Selamu, M., Alem, A., …Hanlon, C. (2019). The psychosis treatment gap and its consequences in rural Ethiopia. BMC Psychiatry, 19, Article 325.

Journal Article Type Article
Acceptance Date Sep 10, 2019
Online Publication Date Oct 29, 2019
Publication Date 2019-12
Deposit Date Jan 29, 2020
Journal BMC Psychiatry
Electronic ISSN 1471-244X
Publisher Springer Verlag
Peer Reviewed Peer Reviewed
Volume 19
Article Number 325
Keywords Treatment gap, The Butajira treatment gap questionnaire, Treatment coverage, Treatment access, Severe mental disorder, Low and middle-income country, Developing country
Public URL
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Additional Information Received: 22 October 2018; Accepted: 10 September 2019; First Online: 29 October 2019; : Ethical approval was obtained from the College of Health Sciences Institutional Review Board, Addis Ababa University (Ref. 026/15/Psy) and the University of Cape Town ethics review board (HREC REF: 412/2011). Written informed consent was obtained from literate participants. For non-literate respondents, verbal consent was accompanied by a finger print in the presence of a literate witness. The consent procedure was also approved by the ethics review board. All participants with severe mental illness (SMD) were offered mental health care through the PRIME project. For people with SMD who lacked capacity to consent and were not refusing participation, caregiver permission was obtained.; : The Authors declare that they have no competing interest.