A growing body of global evidence is drawing a clearer line between mental wellbeing and how people experience health care.

A new international study suggests that adults who rate their mental health poorly are also far more likely to report unsatisfactory care, weaker trust in health services, and greater difficulty managing their own health.

The findings add urgency to calls for health systems to treat mental health as a core component of care, rather than a specialist issue on the margins.

The research, published recently in the open-access journal PLOS Medicine, analysed responses from more than 32,000 adults across 18 countries. The participating nations spanned high-, middle-, and low-income settings, offering a rare snapshot of how mental health status intersects with health system performance on a global scale. The results point to a consistent pattern. Poor mental health often travels with poorer experiences of care, regardless of geography or income level.

Rates of depression and anxiety have risen sharply since the COVID-19 pandemic. Lockdowns, economic disruption, grief, and social isolation have left long-lasting marks on mental wellbeing. At the same time, demand for mental health services has grown. Yet up-to-date, population-level data on how people with mental health difficulties navigate health systems remain limited. This study set out to address that gap.

Researchers used data from the People’s Voice Survey, collected in 2022 and 2023. More than 1,000 adults in each country took part, answering questions about their health, their use of services, and their experiences with care. Participants rated both their physical and mental health using a five-point scale, ranging from poor to excellent. They were also asked about their confidence in the health care system, the quality of care they usually receive, and their ability to manage their own health, a concept known as patient activation.

Patient activation refers to how informed, skilled, and confident people feel when managing their health and health care. It includes understanding treatment plans, knowing when to seek help, and feeling able to ask questions or raise concerns. Previous research has linked higher patient activation to better health outcomes. In this study, it emerged as a critical dividing line.

Across all 18 countries, respondents who reported poor mental health also reported lower patient activation. They felt less empowered to manage their conditions. They were more likely to describe their care as low quality. They expressed less confidence in the health care system as a whole. The consistency of these findings stood out. While access to treatment varied widely between countries, the experience gap remained strikingly similar.

People with poor mental health were also nearly twice as likely to report having a chronic physical illness. This overlap underscores the reality that mental and physical health are deeply intertwined. Many individuals do not present with mental health needs alone. They arrive in clinics and hospitals with complex, overlapping conditions that challenge traditional models of care.

The study also revealed wide variation in the proportion of people receiving mental health care. Among respondents with poor mental health, the share who had accessed mental health services in the past year ranged from less than 1 percent in some countries to more than half in others.

Self-reported mental health also differed sharply between countries. Respondents in Nigeria reported the lowest proportion of poor or fair mental health, at under 5 percent. At the other end of the spectrum, nearly 40 percent of respondents in China rated their mental health as poor or fair. These differences may reflect cultural attitudes towards mental health, levels of stigma, economic pressures, or variations in how people interpret survey questions. They may also point to genuine differences in population wellbeing.

Despite these variations, the broader message remained the same. Poor mental health rarely exists in isolation. It shapes how people interact with health services. It influences whether they feel heard, respected, and supported. It affects whether they trust the system meant to care for them.

Confidence in health care systems emerged as a key issue. Respondents with poor mental health consistently reported lower trust. This matters. Trust influences whether people seek care early or delay treatment. It affects adherence to medication and follow-up. Low confidence can widen health inequalities, particularly for those already facing social or economic disadvantage.

The authors of the study describe their work as descriptive rather than causal. The survey cannot determine whether poor mental health leads to worse care experiences, or whether negative experiences of care worsen mental health. In reality, the relationship is likely to run in both directions. A person struggling with depression or anxiety may find it harder to navigate complex systems. At the same time, fragmented, impersonal, or inaccessible care can exacerbate distress.

The researchers argue that health systems need to move away from treating mental health as a siloed service. Instead, mental wellbeing should be integrated across all areas of care. Patients with poor mental health are present in primary care, emergency departments, chronic disease clinics, and maternity services. They often have greater needs and face higher barriers.

One proposed lever for improvement is patient activation. Boosting people’s confidence and skills to manage their health could have wide-reaching benefits. Interventions might include clearer communication, shared decision-making, health coaching, and better continuity of care. These approaches can be especially important for people with mental health difficulties, who may feel overwhelmed or disengaged.

The study also highlights the value of listening directly to patients. The People’s Voice Survey focuses on self-reported experiences rather than administrative data. This perspective captures aspects of care that are often missed, such as respect, understanding, and trust. While such data cannot replace clinical measures, they offer essential insights into how systems are functioning from the user’s point of view.

There are limitations to consider. Self-reported data can be influenced by recall bias or cultural norms. The survey does not capture detailed clinical diagnoses or the severity of mental health conditions. Nor does it reflect individual encounters within specific facilities. However, the breadth of the sample and the consistency of patterns across countries lend weight to the findings.

The authors suggest that countries could use this type of data to compare performance across similar health systems and to track changes over time. Doing so could support continuous improvement. It could also help policymakers identify groups at risk of poor experiences and unmet needs.

The timing of the study is significant. Many health systems are still grappling with the aftershocks of the pandemic. Workforce shortages, long waiting times, and strained budgets are common. Mental health services, in particular, are under pressure. Understanding how people with mental health difficulties experience the system can help guide more effective responses.

Experts involved in the research note that the experience gap they observed was remarkably consistent. Regardless of where people lived, those with poor mental health reported worse care and less trust. This suggests a systemic issue rather than isolated national failures. It points to the need for global learning and shared solutions.

The findings also challenge health systems to look beyond access alone. Reaching people is not enough if the care they receive leaves them feeling unsupported or disempowered. Quality, respect, and communication matter. For people with mental health difficulties, these elements may matter even more.

Mental health has gained visibility in recent years, yet it remains under-resourced in many settings. This study adds another dimension to the conversation. Improving mental health care could have ripple effects across the entire health system. Better mental wellbeing may support better management of chronic illness, greater engagement with care, and stronger trust.

In an era of rising demand and constrained resources, these insights are valuable. They remind policymakers and providers that health systems are experienced by people, not averages. Listening to those experiences, especially among vulnerable groups, is essential.

As countries look to rebuild and reform health services years after the pandemic, the message is clear. Mental health cannot remain an afterthought. It shapes how people experience care, how they trust institutions, and how well they can manage their own health. Addressing it more fully may be one of the most effective ways to improve health systems for everyone.