|Year : 2016 | Volume
| Issue : 3 | Page : 196-212
Republished: Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, 3rd edition
Vikram Patel1, Dan Chisholm2, Rachana Parikh3, Fiona J Charlson4, Louisa Degenhardt5, Tarun Dua2, Alize J Ferrari4, Steve Hyman6, Ramanan Laxminarayan7, Carol Levin8, Crick Lund9, María Elena Medina Mora10, Inge Petersen11, James Scott12, Rahul Shidhaye13, Lakshmi Vijayakumar14, Graham Thornicroft15, Harvey Whiteford16, on behalf of the DCP MNS Author Group17
1 London School of Hygiene and Tropical Medicine, London, UK; Public Health Foundation of India, New Delhi, India; Sangath, Goa, India
2 Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
3 Public Health Foundation of India, New Delhi, India
4 School of Public Health, University of Queensland, Herston, QLD, Australia; Queensland Centre of Mental Health Research, Wacol, QLD, Australia; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
5 Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia; Melbourne School of Population and Global Health University of Melbourne, Melbourne, VIC, Australia
6 Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard and Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, USA
7 Center for Disease Dynamics, Economics and Policy, Washington DC, USA; Princeton Environmental Institute, Princeton University, Princeton, NJ, USA; Public Health Foundation of India, New Delhi, India
8 Department of Global Health, University of Washington, Seattle, WA, USA
9 Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa; Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
10 National Institute on Psychiatry de la Fuente Muniz, Mexico City, Mexico
11 School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
12 The University of Queensland Centre for Clinical Research, Brisbane, Metro North Mental Health, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
13 Public Health Foundation of India, New Delhi, India; CAPHRI School for Public Health and Primary Care, Maastricht University, Netherlands
14 SNEHA, Volunatary Health Services, Chennai, India; Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
15 Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
16 School of Public Health, University of Queensland, Herston, QLD, Australia; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
|Date of Web Publication||3-Nov-2016|
Prof Vikram Patel
London School of Hygiene and Tropical Medicine, London, UK
Source of Support: None, Conflict of Interest: None
The burden of mental, neurological, and substance use (MNS) disorders increased by 41% between 1990 and 2010 and now accounts for one in every 10 lost years of health globally. This sobering statistic does not take into account the substantial excess mortality associated with these disorders or the social and economic consequences of MNS disorders on affected persons, their caregivers, and society. A wide variety of effective interventions, including drugs, psychological treatments, and social interventions, can prevent and treat MNS disorders. At the population-level platform of service delivery, best practices include legislative measures to restrict access to means of self-harm or suicide and to reduce the availability of and demand for alcohol. At the community-level platform, best practices include life-skills training in schools to build social and emotional competencies. At the health-care-level platform, we identify three delivery channels. Two of these delivery channels are especially relevant from a public health perspective: self-management (eg, web-based psychological therapy for depression and anxiety disorders) and primary care and community outreach (eg, non-specialist health worker delivering psychological and pharmacological management of selected disorders). The third delivery channel, hospital care, which includes specialist services for MNS disorders and first-level hospitals providing other types of services (such as general medicine, HIV, or paediatric care), play an important part for a smaller proportion of cases with severe, refractory, or emergency presentations and for the integration of mental health care in other health-care channels, respectively. The costs of providing a significantly scaled up package of specified cost-effective interventions for prioritised MNS disorders in low-income and lower-middle-income countries is estimated at US$3-4 per head of population per year. Since a substantial proportion of MNS disorders run a chronic and disabling course and adversely affect household welfare, intervention costs should largely be met by government through increased resource allocation and financial protection measures (rather than leaving households to pay out-of-pocket). Moreover, a policy of moving towards universal public finance can also be expected to lead to a far more equitable allocation of public health resources across income groups. Despite this evidence, less than 1% of development assistance for health and government spending on health in low-income and middle-income countries is allocated to the care of people with these disorders. Achieving the health gains associated with prioritised interventions will require not just financial resources, but committed and sustained efforts to address a range of other barriers (such as paucity of human resources, weak governance, and stigma). Ultimately, the goal is to massively increase opportunities for people with MNS disorders to access services without the prospect of discrimination or impoverishment and with the hope of attaining optimal health and social outcomes.
|How to cite this article:|
Patel V, Chisholm D, Parikh R, Charlson FJ, Degenhardt L, Dua T, Ferrari AJ, Hyman S, Laxminarayan R, Levin C, Lund C, Mora ME, Petersen I, Scott J, Shidhaye R, Vijayakumar L, Thornicroft G, Whiteford H, on behalf of the DCP MNS Author Group. Republished: Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, 3rd edition. Indian J Soc Psychiatry 2016;32:196-212
|How to cite this URL:|
Patel V, Chisholm D, Parikh R, Charlson FJ, Degenhardt L, Dua T, Ferrari AJ, Hyman S, Laxminarayan R, Levin C, Lund C, Mora ME, Petersen I, Scott J, Shidhaye R, Vijayakumar L, Thornicroft G, Whiteford H, on behalf of the DCP MNS Author Group. Republished: Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, 3rd edition. Indian J Soc Psychiatry [serial online] 2016 [cited 2019 Mar 23];32:196-212. Available from: http://www.indjsp.org/text.asp?2016/32/3/196/193189
The article is being republished from: Patel V, Chisholm D, Parikh R, Charlson FJ, Degenhardt L, Dua T, et al. Addressing the burden of mental, neurological, and substance use disorders: Key messages from Disease Control Priorities, 3rd edition. Lancet 2016; 387:1672-85.
Vikram Patel, Dan Chisholm
Authors contributed equally
| Introduction|| |
The primary goal of Disease Control Priorities in Developing Countries, first published by the World Bank in 1993, is to synthesise evidence of the burden of specific health disorders and, more importantly, the relative effectiveness and cost-effectiveness of interventions so as to assist decision makers in allocating often tightly constrained budgets and ensuring that health system objectives are maximally achieved. The third edition of Disease Control Priorities (DCP-3) aims to provide up-to-date evidence and includes several novel features that build on previous editions, for example by addressing how interventions can be packaged together across a range of delivery platforms and channels (appendix p 1). Here we describe the key findings of the evidence related to mental, neurological, and substance use (MNS) disorders.
MNS disorders are a heterogeneous range of disorders that owe their origin to a complex array of genetic, biological, psychological, and social factors. Although many health systems deliver care for these disorders through separate channels, with an emphasis on specialist services in hospitals, the disorders have been grouped together here because they share several important characteristics, notably: all owe their symptoms and impairments to some degree of brain dysfunction; social determinants play an important part in the aetiology and symptom expression [Panel 1];, they frequently co-occur in the same individual; their effect on families and wider society is profound; they are strongly associated with stigma and discrimination; they often take a chronic or relapsing course; and they all share a pitifully inadequate response from health-care systems in all countries, but particularly in low-income and middle-income countries. This grouping is also consistent with the DCP-3 goals of synthesising evidence and making recommendations across diverse health disorders and with WHO’s Mental Health Gap Action Programme (mhGAP).
In DCP-3, we have considered interventions for five groups of disorders (adult mental disorders, child mental and developmental disorders, neurological disorders, alcohol use disorder, and illicit drug use disorders) and for suicide and self-harm, a health outcome strongly associated with MNS disorders. Within each group, we have prioritised disorders that are associated with high burden and for which evidence exists in support of interventions that are cost effective and scalable. Inevitably, such an approach does not address a substantial number of disorders (eg, multiple sclerosis as a neurological disorder and anorexia nervosa as an adult mental disorder), but our recommendations could be extended to several other disorders that have not been expressly addressed, in particular with respect to the delivery of packages for care. Additionally, some important MNS disorders or concerns are covered in other volumes of the DCP-3 series, notably, nicotine dependence, early child development, neurological infections, and stroke.
In this report, we address five themes. First, we address the question of why MNS disorders deserve prioritisation by pointing to and reviewing the health and economic burden of disease attributable to MNS disorders. Second, we review the evidence of the effectiveness of specific interventions for the prevention and treatment of the selected MNS disorders. Third, we consider how and where these interventions can be appropriately implemented across a range of service delivery platforms. Fourth, we examine the cost of scaling up cost-effective interventions and the case for enhanced service coverage and financial protection for people with MNS disorders. Finally, we consider the barriers and strategies for successful scale-up.
Why MNS disorders matter for global health
The Global Burden of Disease Study 2010 (GBD 2010) identified MNS disorders as significant causes of the world’s disease burden. We use GBD 2010 data to investigate trends in the burden due to MNS disorders. Between 1990 and 2010, absolute disability-adjusted life-years (DALYs) due to MNS disorders rose by 41%, from 182 million DALYs to 258 million DALYs (the proportion of global disease burden increased from 7·3% to 10·4%). With the exception of substance use disorders, which increased in prevalence with time, this increase in MNS-related DALYs was largely due to population growth and ageing. As a group, MNS disorders were the leading cause of years lived with disability (YLDs) globally [Figure 1]. DALYs from MNS disorders were highest during early-to-mid-adulthood, explaining 18·6% of total DALYs in individuals aged 15-49 years as opposed to 10·4% at all ages combined. DALYs from neurological disorders were highest in elderly people. The burden of these disorders contains important gender differences: men accounted for more DALYs from mental disorders occurring in childhood, schizophrenia, substance use disorders, Parkinson’s disease, and epilepsy, whereas more DALYs accrue to women for all other disorders in this group. The relative proportion of DALYs from MNS disorders to overall disease burden was estimated to be 1·6 times higher in developed regions (15·5% of total DALYs) than in developing regions (9·4% of total DALYs), largely due to the relatively higher burden of other health disorders such as infectious and perinatal diseases in developing regions. Because of the larger population in low-income and middle-income countries, however, absolute DALYs from MNS disorders are higher than in high-income countries.
|Figure 1: Proportion of global YLDs and YLLs attributable to mental, neurological, and substance use disorders, 2010|
YLLs=years lost to premature mortality. YLDs=years lived with disability. In GBD 2010 injuries included deaths and YLLs due to suicide. Mental and substance use disorders explained 22·5 million suicide YLLs, equivalent to 62·1% of suicide YLLs or 1·3% of total all cause YLLs. Source: Whiteford et al (2015) and http://vizhub.healthdata.org/gbd-compare/
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Burden due to premature mortality according to GBD2010 might incorrectly lead to the interpretation that premature death in people with MNS disorders is inconsequential. This is because of how causes of deaths are assigned in the International Classification of Diseases (ICD) death-coding system used by GBD 2010. Yet, evidence shows that people with MNS disorders have a significant reduction in life expectancy, with risk of mortality increasing with disorder severity.,, Consequently, we also explore differences between GBD 2010 estimates of cause-specific and excess mortality from these disorders and potential contributors to life-expectancy gaps. Although reported years of life lost (YLLs) accounted for only 15·3% of DALYs from MNS disorders, equivalent to 840 000 deaths, natural history models generated by DisMod-MR estimate that substantially more deaths could be associated with these disorders. Excess deaths from major depression alone were estimated at more than 2·2 million in 2010. This number is significantly higher than other attempts to quantify the same and potentially indicates a much higher degree of mortality associated with MNS disorders than that captured by the assessment of YLLs in GBD 2010. However, because these estimates of excess deaths included deaths from both causal and non-causal origins, they must be interpreted with caution. In relation to excess deaths presented in [Table 1], comparative risk analyses have also highlighted mental and substance use disorders as significant risk factors of premature death from a range of other health outcomes. For example, an estimated 60% of suicide deaths can be reattributed to mental and substance use disorders, which would elevate them from the fifth to the third leading cause of burden of disease.
|Table 1: Cause-specific and excess deaths associated with mental, neurological, and substance use disorders (GBD 2010)|
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These estimates of disease burden do not fully take into account the substantial social and economic consequences of MNS disorders, not only for affected individuals and households but also for communities and economies. Notable examples of such effects include that of maternal mental disorders on the wellbeing of their children, contributing to the intergenerational transmission of poor health and poverty; of substance use disorders on criminal behaviour and incarceration; and of a range of severe disorders on the economic productivity of affected persons and of family members engaged in caregiving. The total economic output lost to MNS disorders globally in 2010 was estimated to be $8·5 trillion, a sum expected to nearly double by 2030 unless a concerted response is mounted. Economic costs attributable to alcohol use and alcohol use disorders alone are estimated to amount to the equivalent of 1·3-3·3% of gross domestic product (GDP) in a range of high-income and middle-income countries, with more than two-thirds of the loss represented by productivity losses. The global cost of dementia in 2010 has been estimated to be $604 billion, equivalent to 1% of global GDP. Additionally, a rising tide of social adversities are recognised to be associated with MNS disorders, with large and growing proportions of the global population affected by conflict or displacement due to environmental degradation and climate change, which bodes for a grim forecast on the future burden of these disorders. Finally, disease burden estimates do not account for the substantial hazards faced by persons with MNS disorders who face the systematic denial of basic human rights, ranging from limited opportunities for education and employment and extending to torture and denial of freedom, sometimes within health-care institutions.
What works? Effective interventions for the prevention and treatment of MNS disorders
The evidence on interventions builds on the recom- mendations of the second edition of Disease Control Priorities (DCP-2),, and is derived from several sources: the mhGAP guidelines developed by WHO for use in non-specialist health settings, which reviewed the literature published up to 2009 using the Grading of Recommendations Assessment, Development and Evaluation (GRADE); other recent reviews where appropriate (eg, Strang and colleagues  for illicit drugs); interventions that required a specialist for delivery, but which had not been addressed by mhGAP or DCP-2, assessed using GRADE; and a review of all reviews, including systematic reviews, and any type of assessment evidence from a low-income and middle-income country published since mhGAP, assessed using GRADE. Our findings are summarised in [Table 2].
|Table 2: Effective interventions for the prevention, treatment, and care of MNS disorders|
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A wide variety of effective interventions comprising drug-based, psychological, and social interventions can prevent and treat the range of the priority MNS disorders. As shown in [Table 2], a set of essential medicines (such as antipsychotic, antidepressant, and antiepileptic drugs) and essential psychosocial interventions (such as cognitive behavioural therapy and parent skills training) can be identified for this group of disorders. Although very few curative interventions for any of these disorders exist, the severity and course of most disorders can be greatly attenuated by psychosocial treatment or generic formulations of essential drugs, including combination drugs tailored to the needs of the individual. A few patients with more severe, refractory, or emergency clinical presentations will need specialist interventions, such as inpatient care with expert nursing for acute psychosis, modified electroconvulsive therapy for severe depression, or surgery for epilepsy. It is important to acknowledge that certain preventive interventions that are primarily intended to target disorders covered in other volumes of DCP-3, such as cardiovascular diseases or neurocysticercosis, will also have benefits for people with MNS disorders such as dementia and epilepsy, respectively. Conversely, some interventions targeting MNS disorders are also associated with benefits to health outcomes for people with other disorders: for example, injury prevention as a result of reduced alcohol or drug use or effective treatment of attention-deficit hyperactivity disorder, and improved cardiovascular health as a result of recovery from depression. Even for those primary disorders for which no highly effective treatments exists, such as autism and dementia, psychosocial interventions have been shown to effectively address their adverse social consequences and support family caregivers.
Despite this evidence, a large proportion of persons affected by MNS disorders do not have access to these interventions. The poor adoption of effective interventions is often affected by concerns about financial resources, an issue that is now being addressed by a mounting evidence base in support of the effectiveness of delivery by non-specialist health workers as well as their cost-effectiveness. A related resource constraint relates to the low availability of appropriately trained mental health workers. Cultural attitudes and beliefs might also pose specific barriers; for example, the symptoms associated with depression or anxiety disorders are commonly interpreted as being normative consequences of social adversity, and proven biomedical causal models are rare, leading to low demand for care and low visibility of the disorder from the view of health policy makers and providers. These competing views will clearly affect the societal preference for and acceptability of investment in the wider adoption of effective interventions for MNS disorders. More generally, stigma, poor awareness, and discrimination are major factors behind the low levels of political commitment and the paucity of demand for care for people with MNS disorders in many populations.
How to deliver effective interventions?
The implementation of evidence-based interventions for MNS disorders seldom occurs through the delivery of single vertical interventions. More frequently, these interventions are delivered via so-called platforms-the level of the health or welfare system at which interventions or packages can be most appropriately, effectively, and efficiently delivered. A specific delivery channel (such as a school or a primary health-care centre) can be viewed as the vehicle for delivery of a particular intervention on a specified platform. Identification of the set of inter- ventions that fall within the realm of a particular delivery channel or platform is of interest and relevance to decision makers because it enables potential opportunities, synergies, and efficiencies to be identified. The identification of interventions that are relevant for a particular platform also reflects how resources are often allocated in practice (eg, to schools or primary health-care services rather than to specific interventions or disorders). We identified three broad platforms to deliver interventions for MNS disorders: population, community, and health-care platforms. Although a fair amount of good evidence from high-income countries exists in support of interventions across these platforms and along the continuum of primary, secondary, and tertiary prevention, the evidence base is far less robust for low-income and middle-income countries. Recommendations for best practice interventions and good practice interventions for these platforms are set out in the table in [Figure 2]. Best practice interventions were identified on the basis of evidence for their effectiveness and contextual acceptability and scalability in low-income and middle-income countries, plus evidence of their cost-effectiveness, at least in high-income countries; good practice interventions were identified on the basis of sufficient evidence of their effectiveness in high-income countries or promising evidence of their effectiveness in low-income and middle-income countries, or both. That evidence of cost-effectiveness does not exist for most interventions in low-income and middle-income countries reflects the absence of evidence rather than the absence of cost-effectiveness.
|Figure 2: Table of intervention priorities for MNS disorders by delivery platform|
Red font denotes urgent care, blue font denotes continuing care, and black font denotes routine care. Recommendations in bold font denote best practice, and recommendations in normal font denote good practice. MNS=mental, neurological, and substance use disorder. ADHD=attention-defi cit hyperactivity disorder. *The management of these complex disorders has no fixed timepoint; for example, in the management of depression, some individuals need relatively short periods of engagement (eg, 6-12 months for a single episode), whereas others might need maintenance care for several years (eg, when there is a relapsing course).
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Population platform interventions typically apply to the entire population and primarily address the promotion of population mental health, prevention of MNS disorders, and demand side barriers such as stigma. Best practice packages include legislative and regulatory measures to restrict access to means of self-harm or suicide (notably pesticides) and reduce the availability of and demand for alcohol (eg, through increased taxes on alcohol products). Good practice packages include interventions aimed at raising mental health literacy and reducing stigma and discrimination. The criminal justice system offers an important channel for delivery of interventions for a range of MNS disorders, notably those associated with alcohol and illicit drug use, behaviour disorders in adolescents, and the psychoses. Other preventive and promotion interventions do not require such a population-wide approach and are best delivered by targeting a group of people in the community who share a certain characteristic or are part of a particular setting; this platform is referred to as the community. Best practice packages at the community level include life-skills training to build social and emotional competencies in children and adolescents, and good practice packages include parenting programmes for parents with infants to promote early child development. Several other good practice packages are reported in [Figure 2].
The health-care platform comprises three specific delivery channels: self-management and care, primary health care, and hospital care. Examples of best or good practice packages for self-care include the self-management of disorders, such as migraine, and web-based psychological therapy for people with depression and anxiety disorders, increasingly enabled by internet and smartphone-based delivery. At the primary health-care level, a range of detection and diagnostic measures as well as the psychological and pharmacological management of disorders, including depression, anxiety disorders, migraine, and alcohol and illicit drug use disorders, can be effective, as can continuing care for severe disorders such as epilepsy or psychosis. The recommended delivery model is that of collaborative stepped care, in which patient care is coordinated by a primary health-care-based, non-specialist case manager who performs a range of tasks including screening, provision of psychosocial interventions, and proactive monitoring, liaising closely with and acting as a link between the patient, the primary care doctor, and specialist services., At the hospital level, first-level hospitals, typically district hospitals, can offer a range of medical care services that provide integrated care for people with MNS disorders by implementing the same packages as recommended for the primary health-care channel, particularly in those domains where MNS disorders frequently co-occur, such as in maternal health, other non-communicable diseases, and HIV,,. In specialist services, which might either be offered within first-level hospitals or in separate specialist hospitals (such as psychiatric hospitals or alcohol and illicit drug treatment centres), interventions focus on the diagnosis and management of complex, refractory, and severe cases of MNS disorders, for example of psychosis, epilepsy, or alcohol use disorders. A small minority of individuals with MNS disorders would need ongoing care in community-based residential facilities because of their disability and lack of alternative sources of care and support. Community- outreach teams that can provide variable levels of intensity of care appropriate for the individual’s needs have a crucial role because their support enables these individuals to function in an independent and supported way, in the community, alongside close liaison with general primary health-care services and other social and criminal justice services.
In humanitarian contexts and emergency-affected populations, such as those arising from conflict or natural disaster, the humanitarian aid and emergency response platform is another delivery channel for much-needed mental health care. These populations are at an increased risk of MNS disorders, which can overwhelm the local capacity to respond, particularly if the existing infrastructure or health system was already weak or might have been rendered dysfunctional as a result of the emergency situation. There is a heightened need to identify and allocate resources for the provision of mental health care and psychosocial support in these settings, both for people with disorders induced by the emergency and for people with pre-existing disorders. In several countries, such emergencies have actually provided opportunities for systemic change or service reform in public mental health care [Panel 2] [Additional file 1]. Alongside efforts to improve levels of contact coverage and bridge the treatment gap for people with MNS disorders, it is imperative to also enhance the quality of service delivery. Quality of care should not be subservient to the quantity of available and accessible services, not least since robust quality improvement mechanisms ensure efficient use of limited resources, and good quality services build people’s confidence in health care, thereby fuelling the demand and increasing use of preventive and treatment interventions.
How much will it cost? Universal health coverage for MNS disorders
For successful and sustainable scale-up of effective interventions and innovative service-delivery strategies (such as task-sharing and collaborative care), decision makers need not only evidence of an intervention’s effect on health, but also their costs and cost-effectiveness. Even when this cost-effectiveness evidence is available, the question remains of whether or how an intervention might confer wider economic and social benefits to households or society, such as restored productivity, reduced medical impoverishment, or greater equality. The methods used for our economic analyses included a review of existing cost-effectiveness evidence and exploratory analyses of the distributional and financial protection effects of interventions (Appendix p 2).
A small but growing economic evidence base exists to inform decision making in low-income and middle-income settings; this evidence base is mainly focused on the treatment of specific disorders such as epilepsy, alcohol use disorders, depression, and schizophrenia. Analysis undertaken at the global level by WHO, updated to 2012 values for DCP-3, reveals a marked variation in the cost per DALY averted, not only between different regions of the world but also between different disorders and interventions; [Figure 3] shows the range for the most cost-effective intervention identified for each of the four disorders mentioned above (appendix p 3)., Brief interventions for harmful alcohol use and treatment of epilepsy with first-line antiepileptic drugs fall towards the lower (more favourable) end of cost per DALY averted, whereas community-based treatment of schizophrenia with first-generation drugs and psychosocial care falls towards the upper end of cost per DALY averted. Estimates from comparable national studies in Brazil, Nigeria, and Thailand, again adjusted to 2012 values, fall in the range of $100–2000 per DALY averted.,, With the exception of an analysis of alcohol-demand reduction measures—which estimated that one DALY could be averted for as little as $200–400 through increases in excise taxes on alcoholic beverages and for $200–1200 through comprehensive advertising bans or reduced availability of retail outlets—hardly any published evidence exists on the cost-effectiveness of population-based or community-level strategies in or for low-income and middle-income settings.
|Figure 3: Cost-effectivenes of selected interventions for mental, neurological, and substance use disorders in low-income and middle-income countries, 2012|
Previously published estimates have been updated to 2012 values (in US$). Bars show the range in cost-effectiveness between six low-income and middle-income world regions defined by the World Bank: sub-Saharan Africa, Latin America and Caribbean, Middle East and North Africa, Europe and Central Asia, South Asia, and East Asia and Pacific (appendix p 3). Source: Hyman et al (2006); Chisholm and Saxena (2012).
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The combined cost of implementing these alcohol- control measures in low income and middle-income settings has been estimated to be $0·10–0·30 per head. A new cost analysis for DCP-3 estimates that a school- based life-skills programme would cost $0·05–0·25 per head (appendix p 5). The annual cost of delivering a defined package of cost-effective interventions for schizophrenia, depression, epilepsy, and alcohol use disorders in two WHO sub-regions (one in sub-Saharan Africa, the other in south Asia) has been estimated to be $3–4 per head. In more affluent regions or in upper- middle-income countries, the cost of such a package is expected to be at least double this amount (appendix p 3).
Beyond health improvement, other important goals or attributes of health systems can be considered, including equity and financial protection. Since many MNS disorders run a chronic and disabling course, often go undetected, and are regularly omitted from essential packages of health care or insurance schemes, they pose a direct threat to the wellbeing and economic viability of households as a result of private out-of-pocket expenditures on health services and goods as well as diminished production or income opportunities. It is therefore incumbent upon governments to ensure that intervention costs are largely met through financial protection measures such as health insurance schemes. In the many low-income and middle-income settings in which rates of service availability and uptake remain very low, however, enhanced financial protection measures alone will not move the population of people with MNS disorders substantially towards a goal of universal health coverage. For that goal to be progressively realised, financial coverage of people with MNS disorders needs to be accompanied by substantially scaled up service coverage.
How to scale up? Health system barriers and opportunities
Despite the evidence summarised in the preceding sections, most low-income and middle-income countries are taking relatively little action to address the health care and other needs of people with MNS disorders. Perhaps the most important reason for this failure to act is the overall poor political commitment to MNS disorders, as evident from the fact that less than 1% of the health budget in most low-income and middle-income countries is allocated to mental health. Similarly, despite the evidence-based calls to action to scale up services for almost a decade, less than 1% of development assistance for health is devoted to mental health care. Key reasons for the absence of political will and consequently low levels of resource allocation include the low demand for mental health-care interventions (in part due to low levels of mental health literacy and high levels of stigma associated with MNS disorders); the absence of technically sound leadership in designing and implementing evidence-based programmes; the absence of adequate absorptive capacity in the existing health-care system; competing policy priorities and vested interests (eg, in relation to the alcohol beverage and pharmaceutical industry and the medical profession); the absence of effective agency and advocacy by affected people; and the persisting belief in the importance of hospital-based specialised models of care, which continue to absorb disproportionate amounts of the already meagre budgetary allocations for this sector. To add to this list is the reality that the evidence synthesised in this paper has limitations, particularly the substantial gaps in the evidence in support of some interventions in low- income and middle-income countries and limited effectiveness of the best available interventions for some disorders. To address this formidable list of barriers, the scaling up of interventions for people with MNS disorders will require an approach that embrace public health principles, systems thinking, and a whole-of-government perspective, as has been shown by several countries [Panel 2].
Key strategies necessary for health-system strengthening include: the mainstreaming of a rights-based perspective throughout the health system and ensuring health policies, plans, and laws are updated to be consistent with international human rights standards and conventions; implementation of multi-component initiatives to address stigma, enhancement of mental health literacy and demand for care, and mobilisation of people with the disorders to support each other and be effective advocates; engagement of other key sectors that work to improve services for people with MNS disorders, notably the social care, non-governmental organisations, private sector, criminal justice, education, and indigenous medical sectors, as they may have complementary roles; provision of inpatient care in the form of general or district hospital units rather than stand-alone psychiatric hospitals; the creation of a non-specialist cadre for human resources that can be case managers and coordinate the delivery of collaborative care in primary care and other health-care platforms; ensuring the supply of essential medicines at relevant platforms; and investment in research across the translational continuum (from basic scientific discoveries to effective clinical applications to interventions for improving public health). Financing options could include the raising and diversion of income taxes on unhealthy products (such as alcohol and tobacco); emphasis on the use of low-cost generic drugs throughout the health-care system; and reallocation of expenditure on ineffective or low-value interventions (such as irrational use of benzodiazepines and vitamins in primary care). Finally, the embedding of health indicators for MNS disorders within national health information and surveillance systems will be important so that progress and achievements can be monitored and assessed. The WHO Comprehensive Mental Health Action Plan offers a clear roadmap for countries at any stage of the journey to scale up efforts. Some WHO regions (such as the Eastern Mediterranean) have adapted this new policy instrument to initiate consultations with international experts and regional policy makers to develop frameworks for action [Panel 3] [Additional file 2] across all four domains of the Plan, along with priority interventions and indicators for assessment of progress.
| Time to act, now|| |
MNS disorders account for a substantial proportion of the global disease burden. This burden has increased dramatically since 1990 and is expected to rise in line with the epidemiological transition from infectious disease to non-communicable disease, with demographic transition in low-income and middle-income countries, and with the increase in the prevalence of several social determinants associated with these disorders. New analyses presented here suggest that the mortality- associated disease burden is very large and previously underestimated. We have also summarised evidence of several effective treatment and prevention interventions that are feasible to implement across diverse socioeconomic and cultural settings for a range of priority MNS disorders. A very relevant aspect of these disorders is their propensity to strike early in life, which is a key factor behind their large contribution to the global burden of disease. Although several important health-system barriers need to be addressed to scale up the recommendations outlined in this paper, country case studies (panel 2) show that the most important driver of change is political will and commitment in countries and development agencies to allocate the necessary resources and provide technical leadership.
The analyses presented in this DCP-3 volume will be synthesised over the coming months along with the findings and recommendations of eight other volumes, with a view to inform ongoing deliberations around the implementation of the Sustainable Development Goals and other policy agendas. The evidence from this volume alone makes a compelling case to scale up interventions to address the avoidable toll of suffering caused by MNS disorders, not least among the poorest people and least resourced countries in the world. Although our analyses have presented the strong public health and economic evidence to support this investment, a moral case must ultimately be made for the scaling up of health care for the hundreds of millions of people whose health-care needs have been systematically neglected and whose basic human rights routinely denied. The time to act on this evidence is therefore now.
| Contributors|| |
VP and DC provided overall leadership in conceptualising the work described in this paper, conceptualised the structure of the paper, drafted the key messages, and sections of the paper. All authors contributed to drafting of specific sections of the paper and reviewing and commenting on successive drafts including reviewing and approving of the final submission. Specifically, GT and HW helped VP and DC in framing the design of the study. CLe, DC, and RL contributed to discussion on cost-effectiveness. RS and CLu contributed to discussion on health-care platforms. IP contributed to discussion on population and community platforms. FJC, LD, AJF, and HW contributed to the section on burden. SH contributed to discussion on adult mental disorders. TD contributed to the discussion on neurological disorders. LD contributed to discussion on illicit drug dependence. JS contributed to discussion on child disorders. LV contributed to discussion on suicide.
Members of the DCP3 MNS Author Group
Emiliano Albanese (Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging; and National Institutes of Health, Bethesda, WA, USA); Margaret Barry (National University of Ireland Galway, Galway, Ireland); Amanda J Baxter (University of Queensland, School of Public Health, Brisbane, QLD, Australia; Queensland Centre for Mental Health Research, Wacol, QLD, Australia); Vladimir Carli (Karolinska Institutet, Stockholm, Sweden); Fiona J Charlson (School of Public Health, University of Queensland, Herston, QLD, Australia; Queensland Centre of Mental Health Research, Wacol, QLD, Australia; and Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA); Dan Chisholm (Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland); Pamela Y Collins (US National Institute of Mental Health, Bethesda, MA, USA); Abigail Colson (Center for Disease Dynamics, Economics & Policy, Washington DC, USA; and Department of Management Science, University of Strathclyde, Glasgow, Scotland); Louisa Degenhardt (National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW, Australia; Melbourne School of Population and Global Health, University of Melbourne, VIC, Australia; and Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA); Tarun Dua (Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland); Cathrine O Egbe (University of KwaZulu-Natal, Durban, South Africa; and UCSF Center for Tobacco Control Research & Education, San Francisco, CA, USA); Holly E Erskine (School of Public Health, University of Queensland, Herston, QLD, Australia; Queensland Centre for Mental Health Research, Wacol, QLD, Australia; and Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA); Sara Evans-Lacko (Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK); Valery Feigin (Auckland University of Technology’s National Institute of Stroke and Applied Neurosciences, Aukland, New Zealand); Abebaw Fekadu (Addis Ababa University, Addis Ababa, Ethiopia); Alize J Ferrari (School of Public Health, University of Queensland, Herston, QLD, Australia; Queensland Centre for Mental Health Research, Wacol, QLD, Australia; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA); Panteleimon Giannakopoulos (University of Geneva, Geneva, Switzerland); Petra Gronholm (Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK); David Gunnell (University of Bristol, Bristol, UK); Wayne D Hall (Centre for Youth Substance Abuse Research, University of Queensland, Brisbane, QLD, Australia); Steve Hyman (Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard and Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, USA); David Jernigan (Johns Hopkins University Bloomberg School of Public Health, Baltimore, MA, USA); Nathalie Jette (University of Calgary, Calgary, AB, Canada); Kjell Arne Johansson (University of Bergen, Bergen, Norway); Ramanan Laxminarayan (Center for Disease Dynamics, Economics and Policy, Washington, DC, USA; Princeton University, Princeton, NJ, USA; and Public Health Foundation of India, New Delhi, India); Carol Levin (Department of Global Health, University of Washington, Seattle, WA, USA); Mattias Linde (Norwegian University of Science and Technology, Trondheim, Norway; and Norwegian National Headache Centre, Trondheim, Norway); Crick Lund (Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa); John Marsden (National Addiction Centre, King’s College London, London, UK); María Elena Medina-Mora (National Institute on Psychiatry de la FuenteMuniz, Mexico City, Mexico); Itamar Megiddo (Center for Disease Dynamics, Economics & Policy, Washington DC, USA; and Department of Management Science, University of Strathclyde, Glasgow, Scotland); Catherine Mihalopoulos (Deakin University, Melbourne, VIC, Australia); Maristela Monteiro (Pan American Health Organization, Washington DC, USA); Aditi Nigam (Center for Disease Dynamics, Economics & Policy, Washington DC, USA); Rachana Parikh (Public Health Foundation of India, New Delhi, India); Vikram Patel (London School of Hygiene & Tropical Medicine, London, UK; Public Health Foundation of India, New Delhi, India; and Sangath, Goa, India); Inge Petersen (University of KwaZulu-Natal, Durban, South Africa); Michael R Phillips (Shanghia Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; and Departments of Psychiatry and Global Health, Emory University, Atlanta, GA, USA); Martin J Prince (Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK); Atif Rahman (University of Liverpool, Liverpool, UK); Neha Raykar (Public Health Foundation of India, New Delhi, India); Tania Real (National Institute of Psychiatry “Ramon de la Fuente Muniz”, Mexico City, Mexico); JΓΌrgen Rehm (Center for Addiction and Mental Health, Toronto, ON, Canada); Jacqueline Roberts (Autism Centre of Excellence, Griffith University, Brisbane, QLD, Australia); Robin Room (University of Melbourne, Melbourne, VIC, Australia; Centre for Alcohol Policy Research at Turning Point Alcohol and Drug Centre, Fitzroy, VIC, Australia; and Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden); Diego Sánchez-Moreno (Ministry of Health, Mexico); James G Scott (The University of Queensland Centre for Clinical Research, Brisbane, QLD, Australia; and Metro North Mental Health, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia); Maya Semrau (Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK); Rahul Shidhaye (Public Health Foundation of India, New Delhi, India; and CAPHRI School for Public Health and Primary Care, Maastricht University, the Netherlands); Morton M Silverman (Suicide Prevention Resource Center, Education Development Centre, The University of Colorado Denver School of Medicine, Aurora, CO, USA; and The Jed Foundation, New York, NY, USA); Timothy J Steiner (Norwegian University of Science and Technology, Trondheim, Norway; and Imperial College London, London, UK); Emily Stockings (National Drug and Alcohol Research Centre, UNSW Australia, Sydney, NSW, Australia); Kirsten Bjerkreim Strand (University of Bergen, Bergen, Norway); John Strang (National Addiction Centre, King’s College London, London, UK); Kiran T Thakur (Columbia University College of Physicians and Surgeons, New York, NY, USA); Graham Thornicroft (Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK); Stéphane Verguet (Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA); Lakshmi Vijayakumar (SNEHA, Volunatary Health Services, Chennai, India; and Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia); Theo Vos (Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA); Harvey Whiteford (School of Public Health, University of Queensland, Herston, QLD, Australia; Queensland Centre for Mental Health Research, Wacol, QLD, Australia; and Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA).
Declaration of interests
VP, RP, RS, and RL report grants from the Bill & Melinda Gates Foundation during conduct of the study. LD reports grants from Reckitt Benckiser and Mundipharma, outside the submitted work. SH reports grants from the Stanley Center Foundation and personal fees from Novartis and Sunovian. DC, FJC, TD, AJF, CLe, CLu, IP, LV, MEM-M, JS, GT, and HW declare no competing interests.
The Bill & Melinda Gates Foundation provides financial support for the Disease Control Priorities Network project, of which this volume is a part. We thank the Institute of Medicine reviewers, the DCP-3 advisory group, and the WHO-Eastern Mediterranean Regional Office mental health policy meeting participants (London; June 16, 2015) for their valuable comments that improved earlier drafts of this paper. VP is supported by grants from the Bill & Melinda Gates Foundation, Wellcome Trust, National Institute of Mental Health, and UK Aid. GT is supported by the European Union Seventh Framework Programme (FP7/2007-2013) Emerald project and by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King’s College London Foundation Trust. The views expressed are those of the authors and do not necessarily represent the decisions, policies, or views of the UK National Health Service, the NIHR, or WHO. LD is supported by an Australian National Health and Medical Research Council principal research fellowship (#1041472). The National Drug and Alcohol Research Centre at University of New South Wales is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grant Fund. CL is supported by UK Aid and the National Institute of Mental Health.
The article is being republished for educational purpose.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]