Session 2: Carol Brayne

Global mental health & public health

Carol Brayne

Matthew Prina

Cambridge Institute of Public Health

The Cambridge Institute of Public Health (CIPH)

A federation and platform to foster and support public health research, training & service

Content

• Global burden and definitions

• International studies focusing on older population

• What disorders, how common and how important

• Summary

Health “ a state of complete physical, mental, and social well-being, and not merely the

absence of disease or infirmity”

WHO 1946

Prevalence of Mental Disorders

• 450 million people worldwide suffer from neuropsychiatric conditions (WHO 2001)

• 10 % point prevalence of neuropsychiatric conditions in adults (WHO 2001)

• 25 % of individuals will develop one or more mental or behavioural disorder in their lifetime.

Mental Health & Mortality

WHO 2010

Depression leading cause of burden of disease by 2030?

WHO 2004

Barriers to mental health in health careCritical contributory factors include:- Deficiencies in information about prevalence,

impact, and effective interventions. - Stigma and discrimination associated with

‘abnormalities of the mind’- Low numbers and limited types of health workers

trained and supervised in mental health care- Insufficient funding for mental health services- Mental health resources centralised in and near big

cities and in large institutions

Saraceno et al. Lancet 2007; 370:1164-74

Public Mental Health• Main aim: ‘to reduce the incidence, prevalence

and impacts of mental disorders and improving the mental health status of population’ (Oxford Textbook of Public Health, 5th edition)

• Secondary aim: ‘to optimise physical health through mental and behavioural interventions’

• Tools used are similar to other areas of PH: epidemiology, health promotion and prevention, health systems and services development, health economics, and monitoring and evaluation.

Measuring the prevalence of mental disorders

example – later life

Ageing population across the world

Challenges of measurement

-Measurements:- Disagreements about fundamental aspects of diagnoses in

psychiatry- No gold standards- Variety of scales- Measurements applicable in later life- Measurements applicable to different cultures

-Episodic nature of psychiatric conditions.

Comparing international data

• Plethora of scales/methods• Concerns about cultural ‘fit’ • Treatment may need to be culture specific ‘culture bound syndrome’ = disturbed behaviour, highly specific to certain cultural systems, which does not conform to Western nosological entities

• Need cross cultural validity of measurement tools

10/66 (Prince, Ferri and many colleagues)

11 catchment areas / 7 countries (rural + urban) with excellent response rates.

Large study = roughly 2000 participants per centreFull interviews last around 2-3 hours:Collected data on:

Mental disorders (GMS/AGECAT)Physical disordersSocio-demographicsHealth service usageDisabilityBlood samplePhysical examination

10/66 sites

Dementia

*Standardised for age, sex, and education.

Prince et al. Lancet. 2008 August 9; 372(9637): 464–474.

Prevalence of depression

Guerra et al. (submitted)

Needs for care

does not need care

needs care some of the time

needs care much of the time

need for care

Bars show percents

0% 10% 20% 30%

Percent

India (rural)

India (urban)

China (rural)

China (urban)

Mexico (rural)

Mexico (urban)

Venezuela

Peru (rural)

Peru (urban)

DR

Cuba

Need for care ‘much of the time’ independently attributable to different health conditions

Condition PrevalenceAdjusted

Prevalence ratio

PAF

Major Depression

1.5% 2.0 2 %

3 or more physical illnesses

9.9% 1.923%

Stroke 7.8% 2.5

10/66 Dementia

10.8% 17.8 65%

Disability• “The negative aspects of the interaction between an

individual (with a health condition) and that individual's contextual factors (personal and environmental factors)” (WHO)

• The WHO Disability Assessment Schedule (WHODAS) 2.0 was developed as a cross-cultural and culture-fair assessment tool to use in epidemiological studies.

• It covers 6 domains: –Understanding or communication–Getting around (mobility)–Self care–Getting along with people (interpersonal interaction)–Life activities–Participation in society (social aspects of disability).

Dementia was found to be the largest contributor to disability

Median Population-attributable prevalence fractions (IQR) for:

-Dementia = 25.1 % (19.2 – 43.6)-Stroke = 11.4 % (1.8 – 21.4)-Limb Impairment = 10.5 % (5.7 – 33.8)-Arthritis = 9.9 % (3.2 – 34.8)-Depression = 8.3 % (0.5 – 23.0)-Eyesight problems = 6.8 % (1.7 – 17.6)-Gastrointestinal impairments = 6.5 % (0.3 – 23.1)

Overcoming Barriers to Mental Health in Health

Insufficient funding (% health expenditure)

Country Percentage of mental health expenditure

Cuba 5 % Dominican Republic 0.5 %

Peru 2 % Venezuela n/a

Mexico 1 % China 2.0 % India 2.3 %

UK 10 % Netherlands 7 %

Australia 9.6 %

Prina et al. (In preparation)

Treatment gaps for mental disorders - world

Mental Disorder Median treatment gap

Schizophrenia and other non-affective psychotic

disorders 32.2%

Depression 56.3% Dysthymia 56%

Bipolar Disorder 50.2% Panic Disorder 55.9%

Generalised Anxiety Disorder 57.5%

Obsessive Compulsive Disorder

57.3%

Alcohol abuse and dependence

78.1%

Kohn et al. WHO Bulletin 2004

AdvocacyWHO advocacy objectives:- Promotion of human rights of the persons

with mental disorders and their families- Monitoring the life conditions of people with

mental illness and their families- Parity of care needs to be assured in all

health schemes- 10/66 has worked on basic research

through to evidence for impact and advocacy

‘The Movement for Global Mental Health aims to improve services for people with mental disorders worldwide. In so doing, two

principles are fundamental: first, the action should be informed by the best available scientific evidence; and, second, it should be in

accordance with principles of human rights’

http://www.globalmentalhealth.org

Summary

• Defining, measuring and measuring impact key to addressing gaps

• However, from public health angle the drivers of mental health in a population are related to wider factors

• Advocacy needs to involve not only the existing mental health needs of populations but also those being generated by the circumstances in which people grow up and live

Thanks

• Matthew Prina

• 10/66 colleagues who generously share their studies