Artigos

INTRODUCTION
Mental disorders encompass various types of conditions that negatively affect an individual's emotional state and behaviour. They are generally associated with suffering and impairments or limitations in quality of life. Among the mental disorders described in the 11th Revision of the International Classification of Diseases (ICD-11), anxiety and depressive disorders are the most common.1 However, schizophrenia, bipolar disorder, and post-traumatic stress disorder, among other conditions, significantly affect a large portion of the global population, particularly when they are not adequately recognised and treated.2 Mental disorders are among the leading causes of global disease burden and are the primary contributors to disability worldwide.3 These conditions account for 14% of the total global disease burden and 30% of the global burden of non-fatal diseases, a situation exacerbated by low treatment adherence.4
Despite the availability of effective interventions for the treatment of mental disorders, significant gaps in access to and the quality of care persist, especially for more severe conditions.5 International data estimate that between 35% and 50% of people with mental disorders in high-income countries do not have adequate access to treatment. In low- and middle-income countries, this percentage is even higher, ranging from 76% to 85%, highlighting this concern.6 In Brazil, the undertreatment rate is alarming, particularly for depression, where over 70% of individuals do not receive adequate care7
In addition to challenges in accessing treatment, the social determinants of mental health, such as sociodemographic and economic factors, play a crucial role in the prevalence and management of mental disorders. Factors such as gender, age, education, income, and area of residence are relevant determinants in the utilisation of treatments for mental disorders. Studies indicate that men, younger individuals, and those with lower educational attainment are less likely to use medications for treatment. 8–10
Despite the growing relevance of mental health, the scarcity of population-based studies in developing countries, such as Brazil, compromises the ability to plan and implement effective public policies. While mental health services provided by the Unified Health System (SUS) are free for users, their distribution is inconsistent across the nation, resulting in significant disparities in access to care.11 Addressing these inequalities and identifying the sociodemographic factors influencing service utilization are essential for ensuring equitable mental health care for all Brazilians. Population surveys, such as the National Health Survey (PNS), play a fundamental role in evaluating health services and guiding evidence-based policie.12 However, there is a lack of comprehensive analyses investigating different treatment modalities for mental health, particularly in the Brazilian context. Therefore, the present study aims to describe the prevalence of treatments for mental disorders in Brazil, including the use of medication, psychotherapy, and integrative and complementary practices, as well as to identify the sociodemographic factors associated with these interventions.

METHODOLOGY

This study conducted a cross-sectional analysis with a representative sample of the Brazilian population aged 15 years and older, residing in permanent households, using data from the 2019 National Health Survey (PNS 2019).13 The survey included individuals living in private households across the country. In each selected household, one resident aged 15 or older was randomly chosen from a list of qualified residents. Data were collected by trained interviewers using a structured questionnaire. The survey comprised three types of questionnaires: one for the selected resident, another for household information, and a third for data on all residents. In total, the PNS 2019 visited 108,525 households and conducted 94,114 interviews. From this pool of participants, we selected 90,846 individuals who provided complete information on mental health treatments (Flow Chart, Supplementary Figure 1).
For this study, the outcome was the current use of medication, psychotherapy, and integrative and complementary practices (ICP) for mental disorders. A positive response to at least one of the following questions was used as the criterion for defining a mental disorder: "Has a doctor or mental health professional (such as a psychiatrist or psychologist) ever diagnosed you with depression?" and "Has a doctor or health professional (such as a psychiatrist or psychologist) ever diagnosed you with another mental illness, such as anxiety disorder, panic disorder, schizophrenia, bipolar disorder, psychosis, or Obsessive-Compulsive Disorder (OCD), etc.?" Participants with a positive response then are further asked if they were specifically diagnosed with 1) Schizophrenia, 2) Bipolar Disorder, 3) OCD, 4) Other. Participants with a positive response to at least one of these questions were further asked: "Which treatments are you currently undergoing due to your mental illness?" The possible answers were: 1) "Receiving psychotherapy," 2) "Using medication or injections," and 3) "Using acupuncture, medicinal plants and herbal medicine, homeopathy, meditation, yoga, tai chi chuan, or some other integrative and complementary practice". For each of these answers there was a “Yes” or “No” option.
The following sociodemographic information was assessed: sex (male or female); age (15/29; 30/39; 40/49; 50/59; 60/max years); Race/ ethnicity our (non-white or white); living with a partner (yes or no); area of residence (urban or rural); years of education (up to 8; 9 to 11; 12 or more); region of the country (South/Southeast or North/Northeast/Central-West); health insurance coverage (yes or no), and monthly per capita household income based on the Brazilian minimum wage.
Initially, we estimated the prevalence of medication use, psychotherapy, and ICP across mental disorder categories: schizophrenia, bipolar disorder, OCD, depression, and other mental disorders. To evaluate the association between explanatory variables (sociodemographic factors) and treatment through medication, psychotherapy, and ICP in individuals with mental disorders, we employed logistic regression models, calculating crude and adjusted odds ratios (OR) with their respective 95% confidence intervals (CI). The selected covariates were based on evidence from previous related studies. The adjusted multivariate model was developed using a stepwise backward elimination process. Initially, all covariates were included in the model simultaneously. Subsequently, variables with p-values ? 0.05 were progressively removed until only those with p-values < 0.05 remained in the final model. The statistical significance of each variable was assessed using the Wald test, which tests the null hypothesis that the regression coefficient is equal to zero. For categorical variables with multiple categories, one category was set as the reference group, and ORs were estimated for each category relative to that reference. Statistical analysis was performed using STATA 16 software, with the "svy" command. The estimates were appropriately weighted to reflect the complexity of the PNS 2019 sampling design and to ensure national-level representativeness (N = 168,426,190).
The PNS 2019 obtained ethical approval and consent for participation from the National Health Ethics Committee of Brazil (CONEP; process no. 3.529.376). Participation was voluntary, with participants signing informed consent forms. Participants could choose to complete the questionnaire fully or partially. PNS data are publicly available on the Brazilian Institute of Geography and Statistics website, and all information is anonymized. 13

RESULTS
A total of 10,958 individuals, representing 13.1% of the assessed population (95% CI = 12.7-13.5), have received at least one mental disorder diagnosis from a health professional. The prevalence of medication use varied considerably between disorders, being highest for schizophrenia (81.4%, 95%CI= 79.0-83.6) and lowest for depression (50.5%, 95%CI= 48.7-52.2). In contrast, the rates of psychotherapy utilisation were lower compared to medication treatments, ranging from 36.5% (95%CI= 33.2-39.8) for bipolar disorder to 21.7% (95%CI= 20.2-23.2) for depression. ICP (Integrative and Complementary Practices) were the least utilised therapeutic approach, with prevalences ranging from 10.6% (95%CI= 9.0-12.4) for OCD to 3.9% (95%CI= 2.6-5.6) for schizophrenia (Figure 1).
Figure 1 about here
Table 1 presents the prevalence of the three different types of treatment according to sociodemographic characteristics. Medication use was more prevalent among women, and increased progressively with age. Non-white individuals used less medication compared to white individuals. Medication use was also more common among individuals with health insurance, residents of the South/Southeast regions, and those with a family income per capita higher than one minimum wage or between half and one minimum wage, compared to those with an income up to half a minimum wage. However, medication use was more prevalent among individuals with lower educational attainment compared to those with higher education levels.
Psychotherapy use, in contrast to medication use, decreased with increasing age, with the highest adherence seen in the 15–29 age group and the lowest among those aged 60 and older. Other variables significantly associated with psychotherapy use included not living with a partner, having health insurance, living in urban areas, and higher educational attainment.
The sociodemographic profile of individuals using ICP for mental disorder treatment also suggested an association with socioeconomic status, with higher use among individuals with health insurance, urban residents, and those with higher education. Similarly, individuals with higher incomes (>1 minimum wage) reported higher use of ICP compared to those with incomes up to half a minimum wage or between half and one minimum wage (Table 1).
Table1 about here
Table 2 presents the results of bivariate logistic regressions models that tested the association between sociodemographic characteristics and mental health related treatment. Medication use was more likely among women, older individuals, rural residents, those with lower years of education, higher income, White, living in the South/Southeast regions and those with health insurance. Psychotherapy use decreased with increasing age and was lower among individuals with lower educational attainment, rural residents, living without a partner and those without health insurance. ICP use was more common among women, individuals with higher incomes, with health insurance and those with more than 11 years of education. Rural residents were less likely to report ICP use.
Table2 about here
Table 3 presents the results of multivariate logistic regression models. After adjustment, medication use remained more likely among women, individuals aged 60 and older, White individuals, those with lower educational attainment, living in the South/Southeast regions and rural residents. Having health insurance also increased the likelihood of medication use. Psychotherapy use remained lower among older individuals, those with lower educational attainment, and rural residents, while having health insurance and not living with a partner increased psychotherapy use. ICP use was more likely among women, individuals with higher incomes, but less common among those with lower educational attainment.
Table3 about here
DISCUSSION
In the present study, 13.1% of individuals reported having at least one mental disorder, with medication being the most commonly utilized form of treatment. The prevalence of medication use was higher for schizophrenia and lower for depression, while psychotherapy was more prevalent in individuals with bipolar disorder and less prevalent in those with schizophrenia. ICP (Integrative and Complementary Practices) were less frequently used than both medication and psychotherapy, with the highest prevalence observed in cases of OCD and the lowest in schizophrenia. Adjusted analyses revealed distinct sociodemographic profiles for the use of the three treatment types. For example, medication use was more prevalent among women, older individuals, those self-reporting as non-white, those with health insurance, lower educational attainment, rural residents, and those living in the South and Southeast regions of Brazil. Psychotherapy use was associated with younger age, individuals not living with a partner, and those with private health insurance. In contrast, the use of ICP was more prevalent among women, individuals with higher income, and higher educational attainment.
Despite the growing relevance of mental health, there is a lack of research on different treatment modalities for mental disorders, both nationally and internationally. This gap is particularly concerning given the low detection rates of mental disorders reported in national studies.14,15 In Brazil, Fulone et al.16 observed an 82% prevalence of medication use for treating schizophrenia, a figure quite similar to the 81.4% reported in the present study. Tavares et al.12 reported a 52% prevalence of medication use for depression, corroborating our findings of a 50.6% prevalence. Regarding the sociodemographic variables associated with medication use for mental disorders, Rodrigues et al.17 found that medication use was significantly higher among women, older individuals, and residents of the South and Southeast regions.
One possible explanation for this phenomenon is the greater frequency with which women attend consultations for psychological problems. Noia et al.18 reported that women in São Paulo, Brazil, used up to three times more medication than men for mental disorders. Furthermore, Iaroseski et al.19 reported that women seek professional help twice as often as men and tend to follow mental health treatment guidelines more rigorously. The association between having health insurance and the use of medication for the treatment of mental disorders has also been observed in other national studies, such as Almeida et al. 20 and Leal et al. 21, reinforcing that belonging to a higher social class, and possibly having a health insurance, is a facilitator of treatment.
Several factors may be related to these findings. For instance, the South and Southeast regions together account for over 75% of Brazil's psychiatrists and have a higher ratio of psychiatrists per inhabitant than other regions.22 These two regions also provide better-quality mental health care in primary healthcare teams within the SUS 23, in addition to having greater health insurance coverage and better socioeconomic indicators.24 Moreover, a comparative study suggested that the prevalence of access to medications is generally higher in the South compared to the rest of Brazil.25 The South and Southeast regions have shown the greatest socioeconomic development in the country for decades, and in 2022, the Southeast region accounted for 53.3% of the National Gross Domestic Product (GDP).
Our study showed that living in rural areas increases the likelihood of being treated with medication. However, contradictorily, healthcare services in rural areas have historically faced significant deficiencies and limitations 26,27 particularly in mental health care.28,29 Further studies are necessary to better understand this scenario.
Regarding psychotherapy, the findings of this study contrast with previous research. We observed a considerably higher prevalence of psychotherapy use, ranging from 21.7% for depression to 36.5% for bipolar disorder, which is much higher than the 2.3% reported in a prior study.30 In that same study, psychotherapy use was more common among women, those with higher educational attainment, unmarried individuals, and middle-aged people, with lower usage among the elderly.30 Studies in developed countries have also reported greater use of psychotherapy among women.31 A cohort study on factors associated with lower use of psychotherapy in Germany showed that older adults, men, those with lower educational attainment, rural residents, individuals living alone, and those who had sought care from a general practitioner were less likely to seek psychotherapy.31 Contrary to most studies, our findings do not suggest a difference in the prevalence of psychotherapy use between men and women. This absence of a gender difference may reflect a shift towards more equitable access to mental health care in Brazil, where awareness campaigns and services have increasingly been accessible to both sexes.
The indication of psychotherapy in the elderly population is a controversial topic, with studies showing uncertainties in its applicability32 and professional challenges in this regard.33 Living alone is a risk factor for higher levels of loneliness and poorer self-rated health 34, which may explain the higher demand for psychotherapy among these individuals.
Not having health insurance reduced the likelihood of being in treatment with either medication and/or psychotherapy which is associated with indicators of a higher social class such as having private health insurance and higher education. Within the SUS, there is a lack of quality mental health services in primary care 23, alongside several weaknesses in mental health care networks, both in terms of professional teams and pharmaceutical assistance, hindering access to adequate treatment for mental disorders. 35
Our study identified a variation in the use of ICP in the treatment of mental disorders, ranging from 3.9% to 10.6%, contrasting with the 5.2% rate found by Boccolini et al 36 for the general Brazilian population. The prevalence of use in mental health was higher among women, those with higher educational attainment, and those with higher incomes. This finding is similar to that found in previous studies conducted in Brazil. 36–38 A study on the use of ICP by the general population in 21 European countries showed that women use ICP more than men. 39 The prevalence of ICP use was also higher among individuals with higher educational attainment, higher income, and older age. In the present study, a higher prevalence of ICP use was observed among younger individuals compared to those aged 60 and over; however, this was not statistically significant in the adjusted analysis. Studies indicate that individuals with higher educational attainment tend to have greater economic, cultural, social, and intellectual resources throughout life. 40 This may increase access to alternative health treatments, particularly in private services, where ICP are more readily available. In the SUS, there is a low availability of services related to ICP 41, as well as low knowledge and interest among professionals regarding these practices. 42
Among the strengths of this study is the fact that the PNS 2019 is a nationally representative, population-based survey, allowing the generalisation of results to the Brazilian population. Our results offer an overview of the prevalence and sociodemographic factors associated with the use of different treatment modalities for mental disorders, which can contribute to the development of public policies focused on mental health care. However, certain limitations should be noted. The cross-sectional design prevents causal inferences and does not exclude the possibility of reverse causality. Another limitation is the absence of data on the severity or intensity of symptoms. It is acknowledged that the indication for treatment, particularly for medication use, is guided by the severity of symptoms, taking into account the specifics of the mental disorders and the individual. Another relevant limitation is the use of self-reporting for the diagnosis of mental disorders and the treatments received, which may introduce information bias. Ideally, psychiatric assessment should be based on medical records or conducted through structured psychiatric interviews, as frequently recommended in population-based studies across various countries, though rarely implemented due to practical and logistical challenges. Finally, caution is needed to interpret part of our results considering that having had a diagnosis of mental already implies more access to health.
The present study showed that a significant portion of the population suffers from mental disorders, with wide variations in the use of different treatment types according to the mental disorder and sociodemographic variables. Overall, there is a predominance of medication use, followed by psychotherapy and ICP. A proper understanding of the sociodemographic variables associated with treatment use can be useful for mental health public policy, considering not only the breadth and equity of care but also the diversity of therapeutic options. Given the variation in treatment use according to regional and socioeconomic characteristics, it is crucial to develop strategies that specifically address local needs, strengthening community support networks and facilitating integration between different health services. Additionally, the results of the present study highlight the need for investment in training and resources for mental health professionals, as well as awareness campaigns to reduce the stigma associated with mental disorders.

Disclosures: The authors declare that they have no conflicts of interest to disclose.
Data availability: Data of the National Health Survey are publicly available on the Brazilian Institute of Geography and Statistics website: https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?=&t=downloads
Author contributions: NMPS: conceptualization, review & editing; LFNN: conceptualization, review & editing; DMOR: conceptualization, formal analysis, writing original draft, review & editing; AF-C: conceptualization, methodology, formal analysis, writing original draft, review & editing; CZ: writing original draft, review & editing.

Declaração de Disponibilidade de Dados
As fontes dos dados utilizados na pesquisa estão indicadas no corpo do artigo.


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