Global Mental Health Improving Care for Depression Jürgen Unützer, MD, MPH, MA April 1, 2011

Jürgen Unützer, MD, MPH, MA Professor, Psychiatry & Behavioral Sciences Adjunct Professor, Health Services Director, AIMS Center Grant funding – NIH (NIMH) – AHRQ – John A. Hartford Foundation – American Federation for Aging Research (AFAR) – Alaska Mental Health Trust Authority – George Foundation – California HealthCare Foundation – Robert Wood Johnson Foundation – Hogg Foundation for Mental Health Contracts – Community Health Plan of Washington – Public Health of Seattle & King County Consultant – AARP Services Incorporated (ASI) – National Council of Community Behavioral Health Care (NCCBH) Advisor – Carter Center Mental Health Program – Institute for Clinical Systems Improvement (ICSI) – World Health Organization (WHO) updated February 2011

Building on 25 years of Research and Practice in Integrated Mental Health Care University of Washington

Mental Disorders are Rarely the Only Health Problem Mental Health / Substance Abuse Neurologic Disorders 10-20% Diabetes 10-30% Heart Disease 10-30% Chronic Physical Pain 25-50% Cancer 10-20% Smoking, Obesity, Physical Inactivity 40-70%

Improving Care for Depression Common 10% in primary care, more common in patients with chronic medical illnesses Disabling #2 cause of disability (WHO) Deadly Over 30,000 suicides / year Expensive % higher health care costs (ED, inpatient, outpatient, pharmacy)

IMPACT Team Care Model Effective Collaboration PCP supported by Behavioral Health Care Manager Informed, Active Patient Practice Support Measurement Caseload-focused psychiatric consultation Training

IMPACT Doubles the Effectiveness of Depression Care %Participating Organizations 50 % or greater improvement in depression at 12 months

IMPACT Care Benefits Ethnic Minority Populations Areán et al. Medical Care, % or greater improvement in depression at 12 months

Mental Health Integration Program: 18,000 clients served across Washington State

Global Mental Health Refugee / Migrant Health Mental Health (WHO) –Senior Advisor, Depression Initiative & World Health Report ( ) –Member; mhGAP Guideline Development Group ( ) Consultant on Initiatives to Improve Depression Care in –Africa and Latin America

WHO Definition of Health Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1948).

Health Disparities Example from World Health Report 2001 AfghanistanUS Population21.7 million283 million Annual Growth4.8 %1.1 % Population over %16.1 % Fertility Rate Probability of Dying Under age 5 25 %0.9 % Life Expectancy44.6 years76.3 years Healthy Life Expectancy 33.8 years67.2 years

Injuries (9.1%) Noncommunicable conditions (59.8%) Death, by broad cause group in 1999 Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (31.1%) Neuropsychiatric Disorders account for 1.7 % of deaths.

Global Burden of Disease Harvard School of Public Health, World Health Organization, World Bank – 1993 A ‘health gap’ measure: incorporates losses of ‘healthy life’ due to premature death and disability. 1 DALY = 1 year of ‘healthy life lost due to death or disability. References –World Bank (1993): World Development Report. NY, Oxford University Press. –Murray CJL, Lopez A (eds)( 1996): The Global Burden of Disease. Harvard School of Public Health. –Murray CJL, Lopez A (2000): Progress and directions in refining the global burden of disease approach. Health Economics 9:

Injuries (13.9%) Noncommunicable conditions (43.2%) Global burden of disease in disability-adjusted life years (DALYs) in 1999 Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (42.8%) Neuropsychiatric Disorders account for 12.3 % of DALYs.

Increasing Life Expectancy at Birth: focus on noncommunicable diseases Fig 3: UN, The Population Prospects, 1998 up-date

1999 Disease or Injury2020 Disease or Injury Increasing Burden of Noncommunicable Diseases and Injuries Change in rank order of DALYs for the 15 leading causes DALY = Disability-adjusted life year 1. Acute lower respiratory infections 2. HIV/AIDS 3. Perinatal conditions 4. Diarrhoeal diseases 5. Unipolar major depression 6. Ischaemic heart disease 7. Cerebrovascular disease 8. Malaria 9. Road traffic injuries 10. Chronic obstructive pulmonary disease 11. Congenital anomalies 12. Tuberculosis 13. Falls 14. Measles 15. Anaemias 1. Ischaemic heart disease 2. Unipolar major depression 3. Road traffic injuries 4. Cerebrovascular disease 5. Chronic obstructive pulmonary disease 6. Lower respiratory infections 7. Tuberculosis 8. War 9. Diarrhoeal diseases 10. HIV 11. Perinatal conditions 12. Violence 13. Congenital anomalies 14. Self-inflicted injuries 15. Trachea, bronchus and lung cancers Source: WHO, Evidence, Information and Policy, 2000

“An estimated 400 million people alive today suffer from mental or neurological disorders or from psychosocial problems related to alcohol and drug abuse. Dr Gro Harlem Brundtland, Director General WHO Geneva, 12 February 2001 Our advocacy effort will concentrate on reducing stigma associated with mental ill health and neurological disorders and on raising awareness about the many effective, affordable treatments that are available but underused, both in developing and industrialized countries.” Many of them suffer silently and alone. Beyond the suffering and beyond the absence of care lie the frontiers of stigma, shame, exclusion and, more often than we care to know, death.

STOP EXCLUSION DARE TO CARE

Santé mentale: Non à l’exclusion, oui aux soins Mental Health: Stop exclusion – Dare to care Охрана психического здоровья: откажитесь от изоляции - окажите помощь Salud mental: Sí a la atención, no a la exclusión

Global School Contest To raise awareness among youth by addressing issues of stigma and mental health; Three categories: 6-9 years (drawing); years (essay, 250 words); years (essay, 500 words); Public and private schools worldwide; Winners (1 per category) announced on 7 April (countries/regions); 3 global winners honoured at the WHO World Health Assembly in May, 2001.

THE INJURED BUTTERFLY I share a desk with a classmate who walks alone on the playground. Overcome by strong feelings of inferiority, he confines himself to a restricted personal space. He is unwilling to interact with others, and others are unwilling to interact with him. Mental illness has caused him to lose all his friends. His strong feelings of inferiority are due to difficulty in adjusting to a new environment and to the academic pressures. He often goes off by himself and is hostile to the world around him. For example, if the teacher tells us about an accident that resulted in a loss of lives, he would say," "Great! We need to reduce the population!" He often stays awake all night for no apparent reason and then tells others that "I've been working hard (at studying) again!". Innumerable strange incidents like these make it difficult to tolerate his behavior. I always try to avoid him and wish there were some way I wuld not have to share a desk with him. While returning home one day, I saw him squatting alone by some flowery shrubs trying to help an injured butterfly. I was dumbfounded and amazed to find that he was so compassionate! Wasn't he hostile to the whole world? I couldn't help but run over and help him with the butterfly. He glanced gratefully at me and said "Thank you!" At that moment, I felt his trust and for the first time experienced a mutual affinity towards him. I have the distinct feeling that my desk mate is like the injured butterfly. He needs others to rescue him, to help his spirit fly! Written by Tang Shu-wei, 14 yr old girl, Guandong Province, China

Released October 4,

World Health Report 2001 Messages (1-3) Mental health is relevant to all of health. Mental disorders are real, diagnosable, common and universal. If left untreated, they can produce suffering and severe disability in individuals, and major social and economic losses. Mental disorders are treatable. Prevention and treatment are possible and feasible, but currently most sufferers are unreached.

Recommendations 1.Provide treatment in primary care 2.Make psychotropic medications available 3.Give care in the community 4.Educate the public 5.Involve communities, families, and consumers 6.Establish national policies, programs, and legislation 7.Develop Human resources 8.Link with other sectors 9.Monitor community mental health 10.Support more research. World Health Report 2001

Psychiatric beds per 10,000 population

Gregoire Ahongbonon, Ivory Coast “The voice of the voiceless”

Clinical psychologists per 100,000 population

Social workers working in mental health per 100,000 population.

Depressive disorders What are they? depressed mood, loss of interest and pleasure ; symptom severity and duration differentiate them from normal mood changes; bipolar disorders: depression alternates with mania (exaggerated elation or irritability) How many suffer? 3 – 10 % of adults What can be done? antidepressant medications; psychosocial interventions (e.g behavioral activation, cognitive- behavior therapy, problem solving treatment, interpersonal therapy).

ICD-10 Depression At least two of three core symptoms –Low sad or mood –Loss of interest or pleasure in daily activities –Lack of energy or increased fatiguability And at least two of the remaining symptoms –Disturbed sleep –Disturbed appetite –Restlessness or slowing of movements or speech –Feelings of guilt or unworthiness –Reduced self esteem or self confidence –Poor concentration or attention –Thoughts or acts of self-harm or suicide Symptoms are present for at least 2 weeks Mild, moderate, and severe depression

Depression across the globe Depression is a universal phenomenon Differences in presentation –Psychological or somatic symptoms may dominate presentation –Belief that depression results from an unknown medical illness, from possession by evil spirits or supernatural powers –Related disease models (Patel et al 2001) Thinking too much (kufungisisa) in Zimbabwe Neurasthenia (shenjing shuairuo) in China Anxiety (ghabrahat) in India ‘Heart too much’ (pelo y tata) in Botswana

Prevalence of Depression

In China, Suicide is the leading cause of death in persons age In Europe, suicide is the 2 nd cause of death in persons after traffic accidents.

% of Women who have contemplated suicide Experienced physical violence by intimate partner NeverEver Brazil (N=940) 1 21 %48 % Chile (N=422) 2 11 %36 % Egypt (N=631) 2 7 %61 % India (N=6,327) 2 15 %64 % Indonesia (N=765) 3 1%11 % Philippines (N=1,001) 2 8 %28 % Peru (N=1,088) 1 17 %40 % Thailand (N=2,073) 1 18 %41 % 1:WHO (2001), 2:INCLEN - WorldSAFE (2001), 3:Hakimi M et al (2001).

Depression can be reliably diagnosed in primary care. Antidepressant medications and brief, structured forms of psychotherapy are effective for % of those affected and can be delivered in primary care. However, fewer than 25 % of those affected (in some countries fewer than 10 %) receive such treatments. Barriers to effective care include the lack of resources and lack of trained providers.

Treatment of depression in primary care WHO: Sartorius et al, 1995.

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“The WHO mhGAP Intervention Guide will open the door to more opportunities for the management of disorders that contribute to suffering among individuals and their families worldwide” said Thomas Insel, Director, National Institute of Mental Health, USA.

Questions What can we learn from effective treatment programs in developed and developing countries? What are the best opportunities and ‘platforms’ to provide treatment? What can we do here at UW to help advance effective treatment for common mental disorders worldwide?