The global burden of disease Flashcards
Where was global health founded?
North America
What does global mental health represent?
New ways of thinking about and addressing health challenges in all world regions
What is the central aim of global mental health?
To improve health while addressing inequities between and within countries
What makes global health truly global?
Concerns high, middle and low income countries
- economic shocks
- influenza pandemics
- antibiotic resistance
What is prominent in global mental health compared to global health?
Inequities more pronounced in mental health than in any other domain of health
- treatment gap can be as much as 90% for serious mental illness in LMICs
Why is the mental health treatment gap so significant in low-income countries?
- Most people with mental disorders live in LICs
- Yet, most specialists are in HICs
What was the primary focus for the global mental health movement?
To be an effort to reduce the pronounced inequities in access to care
What did the Lancet series (2007) present?
> Why there can be no health without mental health
> Scarcity and inefficient use and distribution of mental healthcare resources
> Evidence that treatments could be administered by non-specialists in low-income settings
-> Scale up accessible, affordable, equitable care
What was the development of the global mental health field since the Lancet series (2007)?
> PLOS Medicine Series
> WHO Mental Health Gap Action Plan (2008):
- guidelines for care by non-specialists in LMICs
- training and guidance on implementation
> Second Lancet series (2011):
- reviewed progress in scaling up
- child and adolescent mental health
> Increase in research funding
- particularly action research since 2010
What characterises the action research developing since the new funding in 2010?
> Increased awareness within LMIC
> 2013 WHO Mental Health Gap Action Plan
-> Committed governments to action and to invest with key measurable indicators of progress
Are mental health disorders universal or culture-specific?
Both
- ethnographic research -> major categories of mental disorders tend to be present, burdensome and impactful
What did the ethnographic research of Wig and colleagues (1980) in Sudan, North India and the Philippines show?
> Community informants in each region
- community and religious leaders
- traditional healers
- Primary care workers
- Local residents
> They recognised vignettes of mental and neurological disorders (epilepsy, mental retardation, psychosis, depression)
- key features AND carefully culturally adapted
- distinguished and measured conditions
> All conditions considered serious
- psychosis felt likely to have most adverse impact on social functioning, work and community participation
What is the contrast between LMICs and Western expressions of illness?
How health conditions are perceived, understood and expressed is highly culturally-variable
-> same condition BUT very different explanatory models heavily influenced by culture
e. g.:
- West: help-seeking from psychologist or psychiatrist
- Zimbabwe: “I might be possessed by a spirit - I should see a spiritual healer”
What is the importance of culture in the delivery of care?
Culture influences almost everything in delivery of care:
- how people present
- how they understand and explain their condition
- words used to describe their distress
- wether, how, when and from whom, are people likely to seek help
Why do commonalities make cross-cultural studies valid?
- It is possible to study the same thing in broadly the same way, meaningfully across cultures
- Commonalities are most striking
Why is there no health without mental health?
Sheer burden of mental disorder worldwide
- something that contributes to loss of years of healthy active life
How do you calculate the Disability-Adjusted Life Years (DALY) indicator?
Years of life lost from premature mortality
+
Years lived with disability
What is the contribution of neuropsychological (mental, neurological and substance use) disorders to the global burden of disease (2015)?
Nearly 15% of total global burden of disease accounted for by neuropsychological disorders
(mental, neurological, substance use)
Why is the proportion of neuropsychological disorders in the total burden of disease lower in low income countries (10%) compared to middle income (15%) and high income countries (28%) (Whiteford et al., 2015)?
Because the total burden of disease in LICs is much higher compared to MICs and HICs
What is observed in the variation of the burden of mental disorders and the total burden of disease between world regions (by income level)?
> Little variation of the burden of mental disorders and its subgroups (neurological, substance use) between world regions
> Total burden of disease does vary
- main component is communicable, perinatal and maternal disorders
What does non-communicable disease (NCD) mean?
Non transmissible disease
What is observed in mental, neurological and substance use disorders over time (by age)?
> Typical onset in adolescence and young adulthood
> Neurological disorders peak in late life (80+)
Why do neurological disorders peak in late life (80+)?
Age-dependent onset of dementia among older people
What is the consequence of the ageing global population?
Middle-age population size is growing, particularly in less-developed countries
-> increases over time the absolute and relative burden of mental disorders
What is the state of the mental healthcare funding?
Even though mental disorders (chronic NCDs) are the largest portion of the Global Burden of Disease chart
- it is not reflected in relative priorities given to research funding, prevention and care
What would be the impact of effective prevention of mental disorders in terms of number of suicides?
50 to 80% of all suicides (one million each year) could be prevented
What is the part of serious mental disorders in the increased non-suicide mortality?
People living with serious mental disorders have approx. 2x risk of dying from other causes not due to lifestyle differences
- depression, schizophrenia, bipolar disorder, dementia
- inflammatory processes associated with depression may increase risk for heart attacks, stroke
- many drug treatments for mental disorders have important side effects (e.g. obesity, diabetes)
What seems to be most important mechanism in the non-suicide deaths of people living with serious mental disorders?
- Accessing physical healthcare
- Poor quality of care received
What is the cause of the reduction of life expectancy associated with mental health disorders?
Systematic exclusion from accessible healthcare
(even though it’s a basic human right)
- Depression: -10-12 years
- Psychosis: -13-15 years
- Smoking: -6 years
- Morbid obesity: -8 years
What did the Million Death Study (Patel et al., 2012) reveal?
A huge excess of mortality from suicide among adolescents - particularly women under 25 in India vs. HICs
What are the links between mental disorders and physical ill-health?
These links are protean (frequently changing)
Mental disorder -> reduced help-seeking for physical health condition -> under-detection of physical conditions -> under-treatment and low adherence to treatment recommendations -> worse prognosis and poor outcomes
How is depression associated to cardiovascular disease?
- Depression increase risk of taking up smoking, not giving up smoking and developing hypertension and diabetes
- > depression doubles risk of heart attack
- Reduced adherence to treatment after heart attack
Can more effective detection and treatment of depression improve cardiovascular outcomes?
Better management of depression may improve diabetes control
What is the importance of HIV care and the high levels of its comorbid depression?
Reduced adherence to anti-retroviral treatment
-> viral breakthrough -> increased mortality
What are the negative effects of compartmentalising mental and physical health?
> Underestimates the true impact of mental disorders (e.g. comorbidities with physical conditions)
> Misses the relevance of mental health to priority topics for global health investments
> Separate mental and physical healthcare systems
> Isolated budgets and healthcare
- delivered from underfunded asylum hospitals
- > perpetuates stigma associated to mental disorders
- > extends to service providers
How does the negative effects of isolated mental and physical budgets and healthcare extend to service providers in LMICs?
Underfunding -> mental health is not a popular career choice for many LMICs
How are health priorities determined in LICs?
Health priorities for a minister of Health in LIC still determined largely by the Millenium Development Goal priorities
- improving maternal and child health
- treatment and control of HIV, tuberculosis, malaria
- mental health at the bottom of list
What is the favorable approach to advocate for better mental health in LMICs?
Attending to mental health is important to achieving all the current priority goals
e.g. bi-directional links between perinatal and maternal mental health, pregnancy outcomes and child survival and development
What are the 4 social determinants of the onset and maintenance of adult mental disorders?
- Poverty and its psychosocial stressors
- Gender
- more women than men meet criteria for common mental disorders - Abuse in care facilities and the community
- Legislation
- no adequate protection
- many countries lack legislation
- outdated laws
What was the Erwadi Asylum fire in Tamil Nadu (India)?
> Traditional healing centre for people living with serious mental illness
> Residents were often shackeld and left untended overnight
> 28 died in the fire
What were the consequences of the Erwadi Asylum fire in Tamil Nadu (India)?
> National enquiry
> 5-year mental healthcare plans
- addressing lack of care in rural and underserved communities
What did Thornicroft and colleagues (2009) demonstrate on the discrimination against those with mental disorders?
Global pattern of experienced and anticipated discrimination against people with schizophrenia
- over third of participants anticipated discrimination for job seeking and close personal relationships when no discrimination was experienced
What is the link between poverty and mental disorders?
Mental disorders are both consequence AND cause of living in poverty
Poverty
- > anxiety and depression
- > increased severity of mental disorders
- > longer course of episodes
- > worse outcome
What are the contributing factors in the association of poverty and mental disorders (Lund et al., 2010)?
Life-long disadvantage
- low education
- poor housing
- indebtedness
- inability to make purchases and payments
Which is most effective between poverty alleviation and mental health interventions (Lund et al., 2011)?
- Studies show the impact of poverty alleviation on mental health is inconsistent and inconclusive
- More evidence for the benefits of mental health interventions on poverty
Poverty alleviation interventions
+
interventions to optimise mental health
= increased likelihood of microloans
What is a treatment gap?
The proportion of people who may benefit from mental health interventions but have not yet accessed a service
What is the treatment gap in LMICs (Kessler et al., 2009)?
80% of people who may benefit from mental health interventions but have not yet accessed a service
What characterises the scarcity of healthcare resources in the world (kakumar et al., 2011)?
> Shortages of psychiatrists, psychiatric nurses, psychologists and social workers
> Median figure for psychiatrists in LMICs:
- 0.05 per 100,000
- 0.16 per 100,000
> 76% of countries (for 86% of world’s population) have less than 1 psychiatric nurse per 100,000 population
What is the solution to the current scarcity of healthcare resources?
Task Shifting:
- mental healthcare
What is the basis of task shifting?
- Mental healthcare does not require advanced technology or equipment
- > Use of non-specialised healthcare workers
Which arguments make a strong case for narrowing the gap between burden of disorders and budget?
- Effective and affordable interventions are available
- Decision-makers need also to consider the relative cost effectiveness of alternative uses of available resources
What did the WHO annual surveys of health ministries reveal about the allocation of mental healthcare resources?
Inefficient use of mental healthcare resources:
- 2/3 of all mental health beds are in specialist hospitals (typically urban centres)
- LMICs typically spend 50% of their mental health budget on mental hospitals
What are the four barriers to a more efficient allocation of mental healthcare resources?
- Funding both hospitals and developing community-based systems
- Vested interests
- hospital institutions provide prestige, power and large budgets - Centralised services are not accessible in LMICs where most people live: rural areas
- Cost of access is high and must be combined with high cost of medication and in-patient care
What is the consequence of the high costs of treatment in LMICs?
Vicious cycle:
High costs of access, medication and in-patient care
-> Discontinuation -> Relapse -> Acute treatment -> Catastrophic costs…
What do governments and funders seek to do to “reduce the public health burden and the individual suffering of people with mental health problems worldwide” (Ban Ki-moon - 8th Secretary-General of the UN, 2009)
- Investment
- Identification of sustainable models
“a pro-poor strategy” that “makes good economic sense”
(Ban Ki-moon, 2009)
