According to the Global Burden of Disease Study (GBD) (2023), an estimated 1.17 billion people were living with a mental disorder in 2023, representing a 95.5% increase since 1990. By 2023, these conditions had become the leading cause of years lived with disability globally – overtaking musculoskeletal disorders – and accounted for about 6% of all-cause DALYs (Disability-Adjusted Life Years). These figures, however, are likely an underestimation of the true scale of the problem. In many low- and middle-income countries (LMICs), stigma and limited awareness of mental health conditions continue to act as barriers to disclosure and help-seeking (Saddichha et al. 2023), systematically suppressing reported prevalence below true population levels (Takayanagi et al. 2014).
The COVID-19 pandemic amplified a preexisting, growing burden
The COVID-19 pandemic substantially intensified an already increasing burden of mental disorders, and in doing so, brought it into sharp public and policy focus. Santomauro et al. (2021) estimate that the pandemic was associated with an additional 53.2 million cases of major depressive disorders (a 27.6% rise) and 76.2 million cases of anxiety disorders (a 25.6% rise) globally in 2020 alone – disproportionately affecting young people and women of reproductive age1. The pandemic created a greater urgency for governments to strengthen mental health systems, which has persisted into the period after.
It is important to note that the pandemic period increases occurred against a backdrop of sustained long-run growth in mental health disorders. As Figure 1 below illustrates, the rising trajectory was well-established prior to 2020; the pandemic accelerated rather than generated it. The sharp spike in incidence rates (new cases) caused by COVID-19 was large – by 2020 the actual rate was nearly 60% above the pre-pandemic trend – but largely temporary. By 2023, the incidence rate had returned broadly where the pre-pandemic trend would have predicted, while the longer term burden is carried through higher prevalence (those living with the condition) and loss of DALYs (GBD 2023).
Figure 1. DALYs rate, prevalence rate, and incidence rate for mental disorders, LMICs, 1990-2023
Source: GBD 2023, IHME.
Notes: (i) Figure shows age-standardised rates for all ages, for low- and middle-income countries (LMICs), disaggregated by sex (female, male, and both). (ii) Age-standardised rates adjust for differences in population age structure, allowing comparisons across populations and over time. (iii) ASDR (Age-Standardised DALY Rate) measures years of healthy life lost per 100,000 population; ASPR (Age-Standardised Prevalence Rate) measures the proportion living with the condition per 100,000; and ASIR (Age-Standardised Incidence Rate) measures new cases arising per 100,000 per year. (iv) The dashed vertical line marks the start of the COVID-19 period.
The burden of mental disorders is gendered
In 2023, 620 million women were living with a mental disorder globally, compared to 552 million men, with women accounting for 92.6 million DALYs from mental disorders versus 78.6 million among men (GBD 2023). Depressive disorders and anxiety disorders, the two conditions most prevalent among women, showed the largest absolute increases in prevalent cases over the study period. As shown in Figure 2, in 2023, women in LMICs carried a depressive disorder burden 1.31 times higher than men, a gap that has been widening since 1990 and expanded further during the COVID-19 period.
Panel B reveals an important age dimension: while older women (50-69 and 70+) carry the highest absolute burden, women of reproductive age (15-49) show the steepest upward trend since 1990 – a finding with particular significance given the well-documented link between perinatal depression and adverse infant outcomes (Chisholm et al. 2016).
Figure 2. DALYs rate for depressive disorders by gender and age group, LMICs, 1990-2023
Source: GBD 2023, IHME.
Notes: (i) Panel A plots the female and male ASDR for depressive disorders in LMICs from 1990 to 2023, all ages. The shaded area represents the gender gap, measured as the difference between female and male ASDR per 100,000. (ii) Panel B shows the female ASDR for depressive disorders disaggregated by age group (15-49, 50-69, and 70+ years). (iii) The dashed vertical line marks the start of the COVID-19 period.
This gender disparity reflects structural conditions that existed long before the pandemic. Socioeconomic disadvantage falls disproportionately on women – with strong associations between financial stress and limited educational opportunity, and higher rates of depression and anxiety (Kirkbride et al. 2024). The COVID-19 pandemic deepened these vulnerabilities through three specific pathways. First, women in LMICs, who were already spending three times as many hours as men on unpaid care and domestic work, bore the brunt of school closures and reduced access to informal care networks to a greater extent (Hossain, 2021). Second, employment disruption hit women harder, given their concentration in services, hospitality, and domestic work – sectors that were among the first to shut down and the last to recover (Santomauro et al. 2021). Third, domestic violence increased sharply as women were confined with abusers and cut off from support networks (World Health Organization (WHO), 2021).
In South Asia, the standardised prevalence of depressive disorders ranges from 3% in Pakistan to 4.4% in Bangladesh (Health Science Reports, 2025). In Bangladesh, 19.5% of ever-married women of reproductive age have symptoms of anxiety (Haque et al. 2025); in Mozambique, 10% of married women meet criteria for depression and 11% for anxiety – figures directly linked in the data to lack of household decision-making autonomy (Antabe et al. 2025).
LMICs versus high-income countries
Anxiety disorders represent the single fastest-growing category of mental disorders globally (He et al. 2026), and their distribution across country income groups reveals a particularly stark inequity. In absolute terms, during 1990-2023, high-income countries recorded higher age-standardised DALY rates for anxiety disorders – likely reflecting, in part, better diagnosis and reporting infrastructure. The trend, however, tells a different story: between 1990 and 2023, the DALY rate rose by 49% in high-income countries and 118% in LMICs (GBD 2023), more than double the rate. He et al. (2026) confirm sharp increases specifically in Nigeria, Bangladesh, and Egypt, while noting that part of this rise may be due to improving detection capacity over time. Projections suggest that anxiety disorder prevalence rates in LMICs could rise nearly seven-fold by 2035 if current trends continue, from approximately 5,562 to 38,729 per 100,000, compared to a three-fold increase projected for high-income countries (He et al. 2026). As Figure 3 indicates, the COVID-19 period accelerated this trajectory, with a steeper spike in LMICs.
Figure 3. Age-standardised DALY rate for anxiety disorders, LMICs versus high-income countries and global, 1990-2023
Source: GBD 2023, IHME.
Notes: (i) Figure shows the ASDR per 100,000 population for anxiety disorders, for all ages and both sexes, for LMICs, high-income countries, and globally. (ii) The dashed vertical line marks the start of the COVID-19 period.
Social disconnection as a structural condition
Beneath the clinical burden of depression and anxiety sits a related but distinct problem: loneliness. The WHO Commission on Social Connection (2025) finds that 1 in 6 people worldwide experience loneliness, rising to nearly 1 in 4 in lower-income countries. Loneliness increases the risk of heart disease, stroke, depression, anxiety, dementia, and impaired immune function, and is linked to an estimated 871,000 deaths annually.
The COVID-19 pandemic substantially worsened this: longitudinal data from Canada found that loneliness prevalence rose from 31% pre-pandemic to 51% during the pandemic, with women experiencing a larger increase than men (Kirkland et al. 2023). In May 2025, the World Health Assembly passed its first-ever resolution on social connection (Resolution WHA78.9), recognising loneliness as a standalone global health priority — in part, a direct policy response to the pandemic’s lasting social legacy (WHO, 2025). In the United Kingdom, Dotsikas et al. (2023) analyze longitudinal data and find that loneliness alone accounted for 83.9% of the gender gap in mental health during the pandemic — more than unpaid labour, childcare, or employment disruption combined.
The conventional framing positions loneliness as a problem of ageing, affluent societies in the West. The evidence disputes this on both counts. On age, Abdalla et al. (2026), drawing on nationally representative survey data from 7,997 adults across eight countries including India, Nigeria, Indonesia, Brazil, and the Philippines, find that nearly half of adults aged 18-24 report loneliness, compared to around 30% of adults aged 55 and older. A key reason is the replacement of in-person interaction with social media and digital connection. Women and lower-income individuals reported consistently higher levels, and those experiencing loneliness had nearly three times the odds of depression and four times the odds of generalized anxiety. On geography, Leblang and Wesselbaum (2025), in a study of 218,000 respondents across 148 countries, find loneliness is highest in low-income countries and Sub-Saharan Africa, rather than high-income settings.
Zooming in on the causes, Wilkinson (2022) argues that the language of a “loneliness epidemic” casts the problem as one of individual failing, while the real drivers are economic precarity, erosion of community institutions, and displacement. Kirkbride et al. (2024) add that acute shocks — food and energy crises, conflict, and economic disruption – reduce social connectedness while simultaneously deepening poverty. For women in LMICs, these shocks tend to be more severe and less cushioned by social protection, making loneliness not an accompaniment to mental illness but a structural driver of it.
Health systems are not prepared
The health system response in LMICs has been almost entirely inadequate. Moitra et al. (2022) find that treatment coverage for major depressive disorder in LMICs is around 20% for any contact with a health professional, dropping to just 3% for minimally adequate treatment (defined as at least four visits to a mental health professional or equivalent pharmacological care within a year), compared to 23% for minimally adequate treatment in high-income countries.
Across the 2000-2019 period, no significant improvement in coverage was observed. The same study finds that private insurance is the strongest single predictor of receiving effective treatment for depression in LMICs. Women in LMICs are systematically less likely to hold formal employment – the most common route to private insurance. The treatment gap therefore operates partly as a financing gap, and that financing gap is gendered.
United for Global Mental Health (2023) documents that LMICs allocate less than 1% of their health budgets to mental health, against a WHO minimum recommendation of 5%. Median government expenditure on mental health stands at US$0.08 per capita in LMICs, compared to US$52.73 in high-income countries.
Figure 4. Mental health spending as a percentage of total government health expenditure, by income group and WHO region
Source: World Health Organization(WHO). Mental Health Atlas 2024.
Notes: (i) Figure shows median government mental health expenditure as a percentage of total government health expenditure. (ii) The dashed line represents the WHO minimum recommended allocation of 5%. (iii) LIC = low-income countries; LMIC = lower-middle-income countries; HIC = high-income countries; AFR = African Region; SEAR = South-East Asia Region; EMR = Eastern Mediterranean Region; WPR = Western Pacific Region; AMR = Region of the Americas; EUR = European Region.
The Bloom Wellbeing Fund (2025) adds that 84% of what little is spent in LMICs goes to psychiatric hospitals, the least accessible and least scalable form of care. The 2025 US and donor aid cuts have compounded this further. Only 5,908 mental health workers received training in 2025, compared to 55,911 in 2024, and the number of people reached by mental health programs fell from 981,850 to 207,030 – meaning three quarters of a million people immediately lost access to care (GMHAN and MHIN, 2025). Among those affected: more than 310,000 torture survivors, 82,000 LGBTQI+ people, 400,000 women, and 255,000 children. These cuts arrive against a pre-existing financing gap of at least US$200 billion in global mental health. UN Women (2026) report that at least one million women and girls have lost access to psychosocial support since January 2025, with 88% of women-led organizations saying the mental health of the women they serve is deteriorating.
This underinvestment is not fiscally neutral. Governments that underfund mental health do not save money – they defer costs onto households, labour markets, and economies. Chisholm et al. (2016) find that a US$147 billion investment in scaling up treatment for depression and anxiety across 36 countries would generate US$310 billion in returns, a benefit-to-cost ratio of 3.3 to 5.7 to 1. The returns are driven primarily by productivity gains, reduced absenteeism at work, and greater workforce participation among treated individuals, alongside 43 million additional years of healthy life gained over the scale-up period.
Community over clinic
Kohrt et al. (2023) argue that task-shifting to trained community health workers (CHWs) is a viable pathway to closing the treatment gap at scale in LMICs. Women are particularly more likely to seek help through community pathways than through specialist facilities, which can carry stigma and may require male family members’ permission to access. Female CHWs in Kenya, India, and Pakistan have demonstrated effectiveness in reaching women with perinatal depression, postpartum anxiety, and trauma-related conditions.
Several country experiences demonstrate what this looks like in practice. In India, The MANAS trial in Goa, by Patel et al. 2010 showed that lay health counsellors achieved clinical outcomes approaching those of specialist services for depression and anxiety. In Brazil, Law 10.216 (2001) replaced psychiatric hospitals with community-based Psychosocial Care Centres; Dias and Fontes (2024) confirm the reform increased outpatient care and reduced long-stay hospitalizations. In Ethiopia, Giorgis et al. (2021) document how 244 health centres completed WHO mhGAP training, with The Lancet noting that “Ethiopia had created a model to improve primary health care for others to follow.” The consistent lesson across all three is that task-shifting works best when integration is gradual and supervision is sustained.
High-income country evidence points in the same direction. Sweden, ranked the top-performing mental health system globally in 2023 and 2024, combines three structural features that distinguish it from most LMIC systems (Commonwealth Fund, 2026). First, universal coverage, whereby 100% of residents are entitled to publicly funded mental health care at no or minimal cost at the point of access. Second, a community-first service model, in which primary care centres act as the first point of contact for mental health, with a focus on early intervention and reducing the need for hospitalization. Third, a 10-year national strategy for mental health and suicide prevention, adopted in January 2025, specifically designed to improve mental health across the population, lower suicide rates, and reduce differences in mental health outcomes across social groups. In 2020, Sweden had 233 mental health professionals per 100,000 people, well above the high-income country average of 62.
The United States presents a contrasting case. Despite spending more on mental health in absolute terms than any other country, it has the highest suicide rate among high-income nations. The system’s failures are structural: it is fragmented, insurance-based, and relies excessively on emergency departments as a point of access for those who cannot afford outpatient care – one in four adults with mental health needs did not receive care because of cost (Commonwealth Fund, 2024). High spending alone does not determine outcomes – the structure of how resources are deployed matters.
Overall, the evidence shows that outcomes improve when care moves closer to people. For women in LMICs, who carry the heaviest share of the burden and face the steepest barriers to specialist care, community-based models may be an effective substitute or bridge to specialized treatment.
In our next blog, we examine intimate-partner violence – a significant structural driver of mental disorders among women in LMICs – its scale, consequences, and the role that health systems can play in responding to it.
FOOTNOTES
1For young people, the key reasons are given as school closures, disruption of social development, and economic uncertainty about the future, while for women of reproductive age, the main factors are domestic violence, unpaid care responsibilities, and loss of livelihoods.
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