Written by Rumi Kato Price, PhD, MPE, professor in the Department of Psychiatry at the School of Medicine; and Porpong (Paul) Boonmak, student at the Washington University School of Medicine
Did you know that, globally, severe episodic phase of major depression is judged even more disabling than untreated AIDS? The level of disability of severe major depression is even worse than heroin and other opioid dependence. These are some results of the landmark global burden of disease study series carried out by large multidisciplinary and international groups of researchers led by the Institute of Health Metrics and Evaluation (IHME).1
In the old days, when mental health researchers had neither adequate tools nor global databases to measure the societal and economic costs of non-fatal illnesses and injuries globally, it was difficult to communicate the devastating effects of psychiatric illnesses and other behavioral health disorders, such as substance abuse, to policy makers and those who control research funding.
Over the last 25 years, global health researchers from the World Health Organization (WHO) and academic universities developed and refined uniform tools to measure the burden of both fatal and nonfatal diseases such as years lived with disability (YLD) and disability adjusted life years (DALY; the combination of burden of disease due to mortality and disability).
Put on the global scale and all significant diseases combined, mental and behavioral disorders account for the largest proportion of the global burden of diseases, over 22%, measured by years lived with disability (YLD).
The proportional burden of mental and behavioral disorders changed little from 1990 to 2010 when the latest large-scale assessment was conducted (see Figure).2
Depression is the second highest in the global burden YLD, both in 1990 and 2010, although its burden due to years lost to death is unremarkable (about 130 disorders come before depression).3 You may wonder if wealthy counties have dominated the excess burden of depression disability. Actually, high-income North America and Eastern Europe are just about in the middle in the disability burden ranking. There are more nuanced variations within a region than across regions.4 Taken together, psychiatric and behavioral health disorders should be regarded as one of the global priority diseases.
Have the world leaders been listening to the voice of global mental health researchers? The short answer is no, at least not yet. An obvious reason is the historical marginalization of the field of mental health from physical heath. Another reason is resource inequality.
The resource allocation to combat mental health disorders is strikingly well correlated with the wealth of a nation.
The global average of expenditure per capita was $1.63 US dollars in 2011. This is bad enough, but a closer examination shows that mental health expenditure per capita, adjusted for the US dollars, is a log function of gross national income per capita, in that per capita expenditure is $0.20 among the low-income countries, $0.59 among the lower-middle countries, and $3.76 among the upper-middle countries, compared to $44.48 among the high-income countries. In almost half of the world population, one psychiatrist is available for every 200,000 people.5
Stigma – negative attitudes and beliefs that affect multitude of one’s life – associated with mental health and substance abuse disorders is a less tractable and even more problematic barrier. In his October 2013 Ted Talk, Andrew Solomon (the author of The Noonday Demon, which won the National Book Award in 2001) adeptly described a couple who both hid anti-depressant medications from each other in fear that the other spouse would not accept his and her own depression.6 Is depression so shameful that you must hide from even the most important person in your world with whom you share a bed everyday? Or take a medical student’s recent observation: her suicidal classmate was taken by fellow classmates to an emergency department located further out, despite the fact that the nearest emergency department was just a few blocks away. It was probably well intended in order to avoid a potential encounter with anyone in the emergency department with whom this person might have to work in the future. The medical student noted this would not have happened if her classmate was having an equally life-threatening asthma attack.
Stigma buster campaigns, as in any past successful public health campaigns, will need to be multifaceted and necessarily take long-range strategies and implementation. Some good news is that evidence is accumulating showing stigma reduction programs targeting personal stigma and social distance are effective; however, these intervention programs have not found to be effective in reducing perceived or internalized stigmatization.7
Jeffrey Lieberman, a psychiatrist and Chairman of the Department of Psychiatry at Columbia University, discusses the world in which a public health care approach to mental health clinical care and prevention can be promoted without stigma. His public mental health strategies include early detection and referrals in a wide range of existing settings (e.g., educational institutions and work settings); behavioral health collaborative care to introduce a range of lifestyle changes; and comprehensive community mental health care.8 For such strategies to be promoted, a fundamental acceptance of mental illness and substance abuse as a medical illness must occur, so that we ALL perceive mental illness just the same way as we see asthma, back pain, cancer, diabetes, and any other chronic illnesses. This is the global premise of the mental health stigma buster movement. Join us to make the world a better place for those living with a mental disorder!
- Salomon JA, et al. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2129-43.
- Becker AE, Kleinman A. Mental health and global agenda. NEJM, 2013: 369:66-73.
- Institute for Health Metrics and Evaluation (IHME): http://www.healthmetricsandevaluation.org/
- Ferrari, et al. Burden of depressive disorders by country, sex, age, and year: findings from the Global Burden of Disease Study 2010. PLoS Med 10(11): e1001547. doi:10.1371/journal.pmed.1001547.
- World Health Organization. Mental health atlas 2011. Available at: http://apps.who.int/iris/bitstream/10665/44697/1/9799241564359_eng.pdf
- Solomon A. Depression, the secret we share. Available at: http://www.ted.com/talks/andrew_solomon_depression_the_secret_we_share?language=en#t-535522
- Griffith KM, et al. Effectiveness of programs for reducing the stigma associated with mental disorders. A meta-analysis of randomized controlled trials. World Psychiatry 2014;13:161–175.
- Liberman J. What if there was no stigma in mental health. Psychiatry Advisor. 2016. Video available at: http://video.psychiatryadvisor.com/video/Jeffrey-Lieberman-What-If-There?DCMP=EMC-PA_Update&cpn=psych_md&hmSubId=