session 2: carol brayne
DESCRIPTION
Carol Brayne: Global Mental Health & Public HealthTRANSCRIPT
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