1. Harvard University Initiative for Global Health Global Health Challenges Social Analysis 76: Lecture 13

2. Harvard University Initiative for Global Health Burden of Neuro-Psychiatric Disorders Diagnosing and Measuring Mental Ill-Health Unipolar Major Depression Suicide Schizophrenia Health Systems and Mental Health Challenges

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4. Neuropsychiatric disorders, Cause-specific Burden of Disease in DALYs for 2002, Source data: World Health Report 2003

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6. Burden of Neuro-Psychiatric Disorders Diagnosing and Measuring Mental Ill-Health Unipolar Major Depression Suicide Schizophrenia Health Systems and Mental Health Challenges

7. Harvard University Initiative for Global Health A unique aspect of studying major mental disorders such as unipolar major depression, bipolar disorder, schizophrenia or generalized anxiety is that there is no definitive biological, immunological or radiological diagnostic tests, at least at present. Epidemiological measurements and clinical diagnostic practice has varied widely over time and across cultures. Diagnostic and Statistical Manual (DSM) now in its fourth revision has increased standardization. Symptom-Based Definitions

8. Harvard University Initiative for Global Health Five or more of the following in the same 2 week period: 1)Depressed mood most of the day (sad or tearful) 2)Decreased interest or pleasure in all or almost all activities 3)Weight loss or weight gain 4)Insomnia or Hypersomnia 5)Psychomotor agitation 6)Fatigue or loss of energy 7)Feelings of worthlessness 8)Diminished ability to think 9)Recurrent thoughts of death or suicidal ideation DSM IV Criteria for Major Depression

9. Harvard University Initiative for Global Health Research suggests that the way in which depression is manifested in terms of the most common set of symptoms varies by culture. For example, in East Asia it is much more common for patients to report somatic symptoms such as weight loss/gain, changes in sleep rather than feeling sad or blue. Cultural Variation in Presentation

10. Harvard University Initiative for Global Health Cultural variation in the presentation of a mental disorder is compounded by cultural variation in the way in which survey items used to detect mental illness appear to function differently in different cultures. How can we distinguish real variation in the way a mental disorder is manifested from variation in the way individuals from different cultures respond to the same survey questions? Differential Item Functioning Across Cultures

11. Harvard University Initiative for Global Health A feeling that your thoughts were being directly interfered or controlled by another person, or your mind was being taken over by strange forces?

12. Harvard University Initiative for Global Health Burden of Neuro-Psychiatric Disorders Diagnosing and Measuring Mental Ill-Health Unipolar Major Depression Bipolar Disorder Schizophrenia Health Systems and Mental Health Challenges

13. Harvard University Initiative for Global Health Approximately 55% have recurrent episodes Average duration of an episode is 6 months Female prevalence is 1.5-2 times higher than male Apparent variation across different cultural, economic and social groups Spectrum of severity of unipolar major depression blends in with dysthymia Newer studies suggest recurrent depression begins in adolescence Epidemiology of Depressive Episodes

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16. Few studies demonstrating effective prevention. Screening high risk groups: post-partum depression, previously depressed individuals may work. Risk factor studies suggest that family history, child abuse and substance abuse are risks. Preventive Interventions

17. Harvard University Initiative for Global Health Many treatment options and combinations have been proposed and tested: 1)Tricyclic antidepressants – require 3-4 weeks of therapy before impact, % effectiveness? 2)Psychotherapy – about equally effective in studies. 3)SSRIs – slightly more effective than tricyclics but with better side effect profiles. More effective for youths and adolescents. 4)Proactive collaborative therapy combined with antidepressants – most effective in studies. Treatment Interventions

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19. Burden of Neuro-Psychiatric Disorders Diagnosing and Measuring Mental Ill-Health Unipolar Major Depression Suicide Schizophrenia Health Systems and Mental Health Challenges

20. Harvard University Initiative for Global Health Important to note that despite the obvious link between depression and suicide, trials to date have not shown that treatment for depression reduces the risk of suicide. Antidepressants appear to increase the risk of suicidal ideation in children and adolescents. At a population level, trends in suicide rates across countries and across age-groups appear to not be explained by variation in the prevalence of depression. Depression and Suicide

21. Harvard University Initiative for Global Health Gunnel and Lewis 2005

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24. Burden of Neuro-Psychiatric Disorders Diagnosing and Measuring Mental Ill-Health Unipolar Major Depression Suicide Schizophrenia Health Systems and Mental Health Challenges

25. Harvard University Initiative for Global Health Three types of symptoms: 1)Psychotic symptoms: loss of contact with reality, false beliefs (delusions), perceptual experiences not shared with others (hallucinations) or bizarre behaviours 2)Negative symptoms: diminished or absent emotions and behavioural responses, blunted affect (immobile facial expressions, monotonous voice tone), anhedonia, apathy and alogia (reduced quantity of speech) 3)Cognitive impairment Schizophrenia

26. Harvard University Initiative for Global Health Onset at ages 16-30 rarely after 45 Slow development over first 5 years beginning with negative symptoms Later onset associated with better social functioning once on therapy 60-84% of monozygotic twins will develop schizophrenia if other twin has schizophrenia Risk of schizophrenia increases by prenatal and perinatal events Schizophrenia associated with poverty Epidemiology of Schizophrenia

27. Harvard University Initiative for Global Health Incidence rates in the age-group 15-44 range from 11- 45 per 100,000 Prevalence rates for the population as a whole range from 0.2%-0.9% There is little sex difference in incidence Epidemiology of Schizophrenia

28. Harvard University Initiative for Global Health No clear evidence of methods to prevent schizophrenia Focus is now on early intervention during prodromal phase. Encouraging preliminary studies but Cochrane review concludes no evidence of effect. Mainstay of management is pharmacotherapy. Primary component is classic or atypical anti-psychotics. No randomized clinical trials of psychodynamic or psychoanalytic therapy. Empirical support for psychosocial interventions having a beneficial effect above and beyond pharmacotherapy. Interventions

29. Harvard University Initiative for Global Health Analysis of Australia by Andrews et al. Found that optimal management of schizophrenia with a combination of pharmacological therapy and psychosocial interventions would reduce the burden of schizophrenia by 22%. Cost per year of disability averted (YLDs) is about US$70,000. How can a larger share of the burden of schizophrenia be addressed? Maximum Impact with Current Interventions

30. Harvard University Initiative for Global Health Burden of Neuro-Psychiatric Disorders Diagnosing and Measuring Mental Ill-Health Unipolar Major Depression Suicide Schizophrenia Health Systems and Mental Health Challenges

31. Harvard University Initiative for Global Health In high-income countries, distinct phases of health system management of mental disorders. 1)Pre 1800, individuals with neuro-psychiatric conditions treated at home by families. 2)With urbanization, rise of asylums where efforts were made to restore individuals to mental health and prevent chronicity. As therapies were ineffective, patient populations grew with declines in living conditions. 3)1890s recognition of mental illness as disease and the hope that scientific study would produce interventions. 4)1950s rise of pharmacotherapy and the promotion of community mental health. Beginning of deinstitutionalization with recognition of the terrible conditions in some hospitals. 5)Deinstitutionalized patients become a major social welfare challenge in terms of unemployment, housing etc. Health Systems

32. Harvard University Initiative for Global Health In developing countries, minimal investment or recognition of mental health. In many countries, patients with severe mental illness institutionalized in abject circumstances. Widespread belief that interventions either do not work or are too costly for low- and middle-income governments. Developing Country Health Systems

33. Harvard University Initiative for Global Health In the last 10 years, there has been a growing recognition that mental health problems are large in developing countries, there are effective therapies and these can be delivered cost-effectively. The implied ‘parity’ of physical and mental illness in the Global Burden of Disease study has been one contributor to this recognition. World Health Report 2001 Mental Health: New Understanding, New Hope has also been an impetus for policy attention. Now in a period of declining international attention, as global agenda is crowded out by AIDS, TB, malaria, polio eradication, and maternal and child health. Global Recognition of Mental Health Problems