VOLUME 4 DISEASE CONTROL PRIORITIES • THIRD EDITION Mental, Neurological, and Substance Use Disorders DISEASE CONTROL PRIORITIES • THIRD EDITION Series Editors Dean T. Jamison Rachel Nugent Hellen Gelband Susan Horton Prabhat Jha Ramanan Laxminarayan Charles N. Mock Volumes in the Series Essential Surgery Reproductive, Maternal, Newborn, and Child Health Cancer Mental, Neurological, and Substance Use Disorders Cardiovascular, Respiratory, and Related Disorders HIV/AIDS, STIs, Tuberculosis, and Malaria Injury Prevention and Environmental Health Child and Adolescent Development Disease Control Priorities: Improving Health and Reducing Poverty DISEASE CONTROL PRIORITIES Budgets constrain choices. Policy analysis helps decision makers achieve the greatest value from limited available resources. In 1993, the World Bank published Disease Control Priorities in Developing Countries (DCP1), an attempt to systematically assess the cost-effectiveness (value for money) of interventions that would address the major sources of disease burden in low- and middle-income countries. The World Bank’s 1993 World Development Report on health drew heavily on DCP1’s findings to conclude that specific interventions against noncommunicable diseases were cost-effective, even in environments in which substantial burdens of infection and undernutrition persisted. DCP2, published in 2006, updated and extended DCP1 in several aspects, including explicit consideration of the implications for health systems of expanded intervention coverage. One way that health systems expand intervention coverage is through selected platforms that deliver interventions that require similar logistics but deliver interventions from different packages of conceptually related interventions, for example, against cardiovascular disease. Platforms often provide a more natural unit for investment than do individual interventions. Analysis of the costs of packages and platforms—and of the health improvements they can generate in given epidemiological environments—can help to guide health system investments and development. DCP3 differs importantly from DCP1 and DCP2 by extending and consolidating the concepts of platforms and packages and by offering explicit consideration of the financial risk protection objective of health systems. In populations lacking access to health insurance or prepaid care, medical expenses that are high relative to income can be impoverishing. Where incomes are low, seemingly inexpensive medical procedures can have catastrophic financial effects. DCP3 offers an approach to explicitly include financial protection as well as the distribution across income groups of financial and health outcomes resulting from policies (for example, public finance) to increase intervention uptake. The task in all of the DCP volumes has been to combine the available science about interventions implemented in very specific locales and under very specific conditions with informed judgment to reach reasonable conclusions about the impact of intervention mixes in diverse environments. DCP3 ’s broad aim is to delineate essential intervention packages and their related delivery platforms to assist decision makers in allocating often tightly constrained budgets so that health system objectives are maximally achieved. DCP3 ’s nine volumes are being published in 2015 and 2016 in an environment in which serious discussion continues about quantifying the sustainable development goal (SDG) for health. DCP3 ’s analyses are well-placed to assist in choosing the means to attain the health SDG and assessing the related costs. Only when these volumes, and the analytic efforts on which they are based, are completed will we be able to explore SDG-related and other broad policy conclusions and generalizations. The final DCP3 volume will report those conclusions. Each volume will provide valuable, specific policy analyses on the full range of interventions, packages, and policies relevant to its health topic. More than 500 individuals and multiple institutions have contributed to DCP3. We convey our acknowledgments elsewhere in this volume. Here we express our particular gratitude to the Bill & Melinda Gates Foundation for its sustained financial support, to the InterAcademy Medical Panel (and its U.S. affiliate, the Institute of Medicine of the National Academy of Medicine), and to the External and Corporate Relations Publishing and Knowledge division of the World Bank. Each played a critical role in this effort. Dean T. Jamison Rachel Nugent Hellen Gelband Susan Horton Prabhat Jha Ramanan Laxminarayan Charles N. Mock VOLUME 4 DISEASE CONTROL PRIORITIES • THIRD EDITION Mental, Neurological, and Substance Use Disorders EDITORS Vikram Patel Dan Chisholm Tarun Dua Ramanan Laxminarayan María Elena Medina-Mora © 2015 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 19 18 17 16 This work is a product of the staff of The World Bank with external contributions. 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All queries on rights and licenses should be addressed to the Publishing and Knowledge Division, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Softcover ISBN (paperback): 978-1-4648-0426-7 ISBN (electronic): 978-1-4648-0428-1 DOI: 10.1596/978-1-4648-0426-7 Hardcover ISBN (hardcover): 978-1-4648-0427-4 DOI: 10.1596/978-1-4648-0427-4 Cover photo: © Curt Carnemark / World Bank. Further permission required for reuse. Cover design: Debra Naylor, Naylor Design, Inc., Washington, DC. Library of Congress Cataloging-in-Publication Data Names: Patel, Vikram, editor. | Chisholm, Dan, editor. | Dua, Tarun, editor. | Laxminarayan, Ramanan, editor. | Medina-Mora, Maria Elena, editor. | World Bank, issuing body, Title: Mental, neurological, and substance use disorders / editors, Vikram Patel, Dan Chisholm, Tarun Dua, Ramanan Laxminarayan, Maria Elena Medina-Mora. Other titles: Disease control priorities ; v. 4. Description: Washington, DC : International Bank for Reconstruction and Development /The World Bank, [2015] | Series: Disease control priorities ; volume 4 | Includes bibliographical references and index. Identifiers: LCCN 2015041175 (print) | LCCN 2015041905 (ebook) | ISBN 9781464804267 (alk. paper) | ISBN 9781464804274 (alk : paper : hc) | ISBN 9781464804281 (ebook) Subjects: | MESH: Mental Disorders. | Developing Countries. | Public Health. | Substance-Related Disorders. Classification: LCC RA790.5 (print) | LCC RA790.5 (ebook) | NLM WA 395 | DDC 362.19689—dc23 LC record available at http://lccn.loc.gov/2015041175 Contents Foreword xi Preface xiii Abbreviations xv 1. Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 1 Vikram Patel, Dan Chisholm, Rachana Parikh, Fiona J. Charlson, Louisa Degenhardt, Tarun Dua, Alize J. Ferrari, Steven Hyman, Ramanan Laxminarayan, Carol Levin, Crick Lund, María Elena Medina-Mora, Inge Petersen, James G. Scott, Rahul Shidhaye, Lakshmi Vijayakumar, Graham Thornicroft, and Harvey A. Whiteford, on behalf of the DCP MNS authors group PART 1 BURDEN 2. Global Burden of Mental, Neurological, and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010 29 Harvey A. Whiteford, Alize J. Ferrari, Louisa Degenhardt, Valery Feigin, and Theo Vos 3. Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 41 Fiona J. Charlson, Amanda J. Baxter, Tarun Dua, Louisa Degenhardt, Harvey A. Whiteford, and Theo Vos PART 2 INTERVENTIONS 4. Adult Mental Disorders 67 Steven Hyman, Rachana Parikh, Pamela Y. Collins, and Vikram Patel 5. Neurological Disorders 87 Kiran T. Thakur, Emiliano Albanese, Panteleimon Giannakopoulos, Nathalie Jette, Mattias Linde, Martin J. Prince, Timothy J. Steiner, and Tarun Dua 6. Illicit Drug Dependence 109 Louisa Degenhardt, Emily Stockings, John Strang, John Marsden, and Wayne D. Hall 7. Alcohol Use and Alcohol Use Disorders 127 María Elena Medina-Mora, Maristela Monteiro, Robin Room, Jürgen Rehm, David Jernigan, Diego Sánchez-Moreno, and Tania Real ix 8. Childhood Mental and Developmental Disorders 145 James G. Scott, Cathrine Mihalopoulos, Holly E. Erskine, Jacqueline Roberts, and Atif Rahman 9. Suicide 163 Lakshmi Vijayakumar, Michael R. Phillips, Morton M. Silverman, David Gunnell, and Vladimir Carli PART 3 POLICIES AND PLATFORMS 10. Population and Community Platform Interventions 183 Inge Petersen, Sara Evans-Lacko, Maya Semrau, Margaret Barry, Dan Chisholm, Petra Gronholm, Catherine O. Egbe, and Graham Thornicroft 11. Health Care Platform Interventions 201 Rahul Shidhaye, Crick Lund, and Dan Chisholm PART 4 ECONOMIC EVALUATION 12. Cost-Effectiveness and Affordability of Interventions, Policies, and Platforms for the Prevention and Treatment of Mental, Neurological, and Substance Use Disorders 219 Carol Levin and Dan Chisholm 13. Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis 237 Dan Chisholm, Kjell Arne Johansson, Neha Raykar, Itamar Megiddo, Aditi Nigam, Kirsten Bjerkreim Strand, Abigail Colson, Abebaw Fekadu, and Stéphane Verguet DCP3 Series Acknowledgments 253 Series and Volume Editors 255 Contributors 257 Advisory Committee to the Editors 261 Reviewers 263 Index 265 x Contents Foreword I personally felt mental health’s deep-rooted importance Although these steps may seem daunting, there is when I returned home to Rwanda in 1996, just after my reason for hope. We can build on the lessons from the people were traumatized by the 1994 Tutsi genocide. At world’s 15-year fight against HIV/AIDS. Across low- and a time when we needed mental health services the most, middle-income countries (LMICs) in the 1990s, both there was only one psychiatrist in the entire country. supply and demand for HIV/AIDS services were absent In an act to survive and rebuild, we turned to our because there were no delivery platforms. No money or communities for healing. Giving a voice to the people support was given to create a delivery structure. No laws and collectively finding a solution to the mental health were written to protect the human rights of those stig- challenges that we faced at that time has helped Rwanda matized by HIV/AIDS. to resiliently move forward on a path toward recovery. Today, it is a drastically different story. Progress This volume of Disease Control Priorities, third against HIV/AIDS for the past 15 years tells us that no edition (DCP3), is thus a welcome call to action for evidence-based, multisectoral, holistic, and rights-based augmenting the response needed to address the growing approach is too sophisticated for LMICs. It demonstrates challenge of mental, neurological, and substance use that specialized referral service systems are possible, (MNS) disorders. Such illnesses lurk in the shadows. even for one of the most complicated and stigmatized Although they account for 10 percent of the global of conditions. It illustrates that as bidirectional supply disease burden, they are left underestimated and unsup- and demand is created, the much-needed link between ported worldwide. patients’ needs and an effective global care response will In the pages that follow, the world has in its hands grow stronger. a series of evidence-based approaches, cost-effective I challenge global leaders to build upon these lessons strategies, and implementation guidelines for MNS learned from the HIV/AIDS response and apply it pos- disorders. This comes at an opportune time. Changing itively to the challenge of MNS disorders. We must no epidemiological and social determinant health profiles longer overlook the deleterious effects that the lack of show the world’s readiness for sustainable development quality MNS services has upon our communities. We goals (SDGs) to aim for universal health coverage. We, should strive to build universal health care systems spe- as global leaders, have a moral obligation to advocate cifically recognizing MNS disorders’ genetic, biological, for comprehensive, effective services backed by human- and cultural roots. And as a global community, I implore rights-oriented legal frameworks to protect those living us to create enabling environments to address the social with MNS disorders as part of this quest toward mean- determinants of health affecting MNS disorders. ingful universal health coverage. Prioritizing the supply This call to action need not be answered alone; let us of quality MNS services at the community level while work together as a global team to change the status quo also improving the demand for such services must come and demand health equity for all. with this advocacy effort. Agnes Binagwaho, MD, MPed, PhD Minister of Health, Rwanda xi Preface Mental, neurological, and substance use (MNS) disor- those conditions that are associated with a significant ders contribute approximately 10 percent of the global global burden. In doing so, we address the majority of burden of disease. They often run a chronic course, the burden associated with these disorders. We have are highly disabling, and are associated with significant organized these heterogeneous groups of disorders into premature mortality. Moreover, beyond their health five groups: adult mental disorders, child mental and consequences, the impact of these disorders on the social developmental disorders, neurological disorders, alcohol and economic well-being of individuals, families, and use disorders, and illicit drug use disorders. The volume societies is enormous. also addresses suicide and self-harm, which are strongly Despite this burden, MNS disorders have been sys- associated with MNS disorders. tematically neglected in most of the world, particu- In addition to providing an up-to-date synthesis of larly in low- and middle-income countries (LMICs), the burden, prevalence, determinants, and interventions with pitifully small contributions to prevention and for prevention and care of the selected disorders, the treatment by governments and development agencies. volume offers a number of novel contributions to the Systematically compiling the substantial evidence that policy-relevant evidence on MNS disorders. already exists to address this inequity is the central goal of volume 4 of Disease Control Priorities, third edition • First, we present a systematic analysis of the excess (DCP3). The evidence presented in this volume will help mortality associated with these disorders, enhancing to build an evidence-based perspective on which policies our understanding of the true burden of disease and interventions for addressing MNS disorders should attributable to them. be prioritized in resource-constrained settings. These • Second, the discussion of interventions embraces a recommendations will be of relevance to ministries of health system perspective, such that, after a review of health and—given the intersectoral nature of the inter- the effective interventions for specific disorders, these ventions and impacts of MNS disorders—to ministries are then organized according to how they might be of health and social welfare, as well as to institutions delivered across three distinct and complementary and donors concerned with sustainable development. platforms: population, community, and health and Reaching a broader audience of academics, research social care. This approach allows us not only to reflect organizations, and public health practitioners is another on how interventions are planned and delivered in goal of this effort. health systems, but also to highlight the potential MNS disorders include a large number of discrete opportunities, synergies, and efficiencies for resource health conditions, each with its own epidemiological allocation. characteristics and interventions for prevention and • Third, in addition to a review of the recent evidence care. These disorders, like most chronic noncommu- for cost-effectiveness, the efforts to scale up the com- nicable diseases, are caused by complex interactions munity-based services for mental health in selected among genetic, biological, social, and psychological LMICs—India and Ethiopia—have been exam- determinants. In this volume, we chose to address only ined through the lens of extended cost-effectiveness xiii analysis to consider the distribution of costs and The findings of this volume make an emphatic case outcomes, as well as the extent to which policies offer for a substantially increased investment in the preven- financial protection to households. tion of and care for MNS disorders. We document highly cost-effective strategies for the prevention of some MNS We thank the large international group of authors disorders and affordable models of care for the deliv- who have contributed to the development of the volume ery of treatment interventions in routine health care for their time, effort, and thoroughness and for presenta- platforms through nonspecialist health workers. Such tion of the evidence succinctly. We hope readers will find investments make economic sense for two reasons: the that the exhaustive information the authors have synthe- interventions we recommend are cost-effective, and the sized is presented in a manner that is clear and engaging. impact of these interventions on social and economic We thank the Bill & Melinda Gates Foundation for outcomes is immense. The counterfactual situation of providing funding support to the DCP3, the Institute of not doing enough, which prevails in most populations, Medicine for coordinating the peer-review process, and is leading to enormous loss of human capital and will the World Bank staff who coordinated the publication hinder the ambition of sustainable development. The of the volume. We are grateful to the DCP3 secretariat, evidence in this volume can be translated into practice in particular, Dean Jamison and Rachel Nugent, for only with strong political will and commitment from their expert inputs on various chapters. In addition, we the governments and developmental agencies who now thank Brianne Adderley, Kristen Danforth, and Elizabeth have to make the necessary investments in their scale-up. Brouwer for their unstinting support, and Rachana We have the evidence to act. There is a moral case to Parikh for coordinating the volume. act. The time to act is now. Vikram Patel Dan Chisholm Tarun Dua Ramanan Laxminarayan María Elena Medina-Mora xiv Preface Abbreviations ACE Assessing Cost-Effectiveness ADHD attention deficit hyperactivity disorder AEDs anti-epileptic drugs AIDS acquired immune deficiency syndrome AIMS Assessment Instrument for Mental Health Systems APA American Psychiatric Association ATS amphetamine-type stimulants AUDs alcohol use disorders BAC blood alcohol concentration BBV blood-borne virus BMT buprenorphine maintenance treatment BPSD behavioral and psychological symptoms of dementia BZP N-benzylpiperazine CBI cognitive behavioral interventions CBT cognitive behavioral therapy CD conduct disorder CDC Centers for Disease Control and Prevention CEA cost-effectiveness analysis ChEI cholinesterase inhibitors CHW community health worker CHOICE Choosing Interventions that are Cost-Effective CI confidence interval CoD cause of death CRA comparative risk assessment CSG Consejo de Salubridad General DALYs disability-adjusted life years DARE Drug Abuse Resistance Education DCP2 Disease Control Priorities in Developing Countries, 2nd ed. DCP Disease Control Priorities DOH Department of Health DFID Department of International Development DSH deliberate self-harm DNA deoxyribonucleic acid DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th ed. DW disability weight ECT electroconvulsive therapy xv ECEA extended cost-effectiveness analysis EEG electroencephalogram EOD early-onset dementia ES effect size FAS Fetal Alcohol Syndrome FASD Fetal Alcohol Syndrome Disorders FRP financial risk protection GBD Global burden of disease GBD 2010 Global Burden of Disease Study 2010 g/dl grams per deciliter GDP gross domestic product GHE Global Health Estimates GNI gross national income GRADE Grading of Recommendations Assessment, Development and Evaluation HCV hepatitis C HICs high-income countries HIV/AIDS human immunodeficiency virus/acquired immune deficiency syndrome HIV human immunodeficiency virus HMT heroin maintenance treatment HR hazard ratio IASC Inter-Agency Standing Committee ICD International Classification of Diseases ICT information and communications technology IHD ischemic heart disease IHME Institute for Health Metrics and Evaluation IMAI Integrated Management of Adult and Adolescent Illness IOM Institute of Medicine IQs intelligence quotients INCB International Narcotics Control Board IOM Institute of Medicine IQR interquartile range LICs low-income countries LMICs low- and-middle-income countries MCH maternal and child health MDMA 3,4-methylenedioxy-N-methylamphetamine MDPV methylenedioxypyrovalerone MHaPP Mental Health and Poverty Project mhGAP Mental Health Gap Action Programme MICs middle-income countries MMT methadone maintenance treatment MNS mental, neurological, and substance use MOH medication-overuse headache MSIC Medically Supervised Injecting Centre NIAAA National Institute of Alcohol Abuse and Alcoholism NCD noncommunicable disease NICE National Institute for Health and Clinical Excellence OCD obsessive-compulsive disorder ONDCP Office of National Drug Control Policy OOP out-of-pocket OR odds ratio OST opioid substitution treatment PAF population attributable fractions PC101 Primary Care 101 xvi Abbreviations PHC primary health care PRIME Programme for Improving Mental health carE PSST problem-solving skills therapy PTSD post-traumatic stress disorder QA quality assurance QALYs quality-adjusted life years QI quality improvement RR relative risk RCT randomized controlled trial SAPS South African Police Service SAR Special Administrative Region SDG sustainable development goal SEL social emotional learning SHR sustained headache relief SIFs supervised injecting facilities SMART Self-Management and Recovery Training SMDs severe mental disorders SMR standardized mortality ratio SNRIs serotonin-norepinephrine reuptake inhibitors SSRIs selective serotonin reuptake inhibitors TC therapeutic community TCA tricyclic antidepressant TPO Transcultural Psychosocial Organization TTH tension-type headache TQ Ten Question UHC universal health coverage UI uncertainty interval UMICs upper middle-income countries UNDCP United Nations International Drug Control Programme UNODC United Nations Office on Drugs and Crime UPF universal public finance WHO World Health Organization WMH World Mental Health WONCA World Organization of Family Doctors YLDs years lived with disability YLLs years of life lost Abbreviations xvii Chapter 1 Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders Vikram Patel, Dan Chisholm, Rachana Parikh, Fiona J. Charlson, Louisa Degenhardt, Tarun Dua, Alize J. Ferrari, Steven Hyman, Ramanan Laxminarayan, Carol Levin, Crick Lund, María Elena Medina-Mora, Inge Petersen, James G. Scott, Rahul Shidhaye, Lakshmi Vijayakumar, Graham Thornicroft, and Harvey A. Whiteford, on behalf of the DCP MNS authors group INTRODUCTION • The disorders frequently co-occur in the same individual. This volume of the third edition of the Disease Control • Their impact on families and society is profound. Priorities (DCP) project addresses mental, neurological, • They are strongly associated with stigma and and substance use (MNS) disorders. MNS disorders are discrimination. a heterogeneous range of disorders that owe their origin • They often observe a chronic or relapsing course. to a complex array of genetic, biological, psychological, • They all share a pitifully inadequate response from and social factors. Although many health systems deliver health care systems in all countries, particularly in care for these disorders through separate channels, with low- and middle-income countries (LMICs). an emphasis on specialist services in hospitals, the disor- ders have been grouped together in this volume to guide Our grouping of MNS disorders is also consistent policy makers, particularly in low-resource settings, as with programs intended to address their health bur- they prioritize essential health care packages and delivery den, exemplified by the Mental Health Gap Action platforms (box 1.1). Programme (mhGAP) (WHO 2008), and with the goals MNS disorders are grouped together because they of the third edition of Disease Control Priorities (DCP3) share several important characteristics, notably: of synthesizing evidence and making recommendations across diverse health conditions. As we emphasize in this • They all owe their symptoms and impairments to volume, these shared characteristics shape the response some degree of brain dysfunction. of countries in addressing the burden of MNS disorders. • Social determinants play an important role in the For example, a strong case is made for an integrated etiology and symptom expression for many of these public health response to these conditions in all coun- disorders (box 1.2). tries, but particularly in LMICs because of the paucity Corresponding author: Vikram Patel, Public Health Foundation of India, the London School of Hygiene & Tropical Medicine, and Sangath, Goa, India, vikram.patel@lshtm.ac.uk. 1 Box 1.1 From the Series Editors of Disease Control Priorities, Third Edition Budgets constrain choices. Policy analysis helps platforms and packages, and by offering explicit con- decision makers achieve the greatest value from sideration of the financial risk protection objective limited available resources. In 1993, the World Bank of health systems. In populations lacking access to published Disease Control Priorities in Developing health insurance or prepaid care, medical expenses Countries (DCP1), an attempt to assess the cost- that are high relative to income can be impover- effectiveness (value for money) of interventions in a ishing. Where incomes are low, seemingly inex- systematic way that would address the major sources pensive medical procedures can have catastrophic of disease burden in low- and middle-income coun- financial effects. DCP3 offers an approach that tries (Jamison and others 1993). The World Bank’s explicitly includes financial protection as well as the 1993 World Development Report on health drew distribution across income groups of financial and heavily on the findings in DCP1 to conclude that health resulting from policies (for example, public specific interventions against noncommunicable finance) to increase intervention uptake (Verguet, diseases were cost-effective, even in environments in Laxminarayan, and Jamison 2015). which substantial burdens of infection and under- The task in all DCP volumes has been to combine the nutrition persisted. available science about interventions implemented DCP2, published in 2006, updated and extended in very specific locales and under very specific con- DCP1 in several respects, including explicit con- ditions with informed judgment to reach reasonable sideration of the implications for health systems of conclusions about the impact of intervention mixes expanded intervention coverage (Jamison and oth- in diverse environments. The broad aim of DCP3 ers 2006). One way that health systems expand inter- is to delineate essential intervention packages— vention coverage is through selected platforms that such as the package for mental, neurological, and deliver interventions that require similar logistics but substance use disorders, in this volume—and their address heterogeneous health problems. Platforms related delivery platforms. This information will often provide a more natural unit for investment assist decision makers in allocating often tightly than do individual interventions, but conventional constrained budgets so that health system objectives health economics has offered little understanding of are maximally achieved. how to make choices across platforms. Analysis of DCP3’s nine volumes are being published in 2015 the costs of packages and platforms—and the health and 2016 in an environment in which serious dis- improvements they can generate in given epidemio- cussion continues about quantifying the sustainable logical environments—can help guide health system development goal (SDG) for health (UN 2015). investments and development. DCP3’s analyses are well-placed to assist in choosing DCP3 differs substantively from DCP1 and DCP2 the means to attain the health SDG and assessing the by extending and consolidating the concepts of related costs for scaled-up action. of specialist services in these settings. Such services have we have considered interventions for five groups been the hallmark of the health system response to these of disorders—adult mental disorders, child men- conditions in high-income countries (HICs). tal and developmental disorders, neurological dis- DCP1 had only addressed a few MNS disorders: orders, alcohol use disorder, and illicit drug use psychosis and bipolar disorder. DCP2 had focused such as opioid dependence—and suicide and self- on the cost-effectiveness of specific interventions harm-health outcomes strongly associated with MNS for burdensome disorders, organized separately for disorders. Within each group, we have prioritized mental disorders, neurological disorders, alcohol use conditions associated with high burden for which disorders, illicit drug use disorders, and learning there is evidence in support of interventions that are and developmental disabilities. In this third edition, cost-effective and scalable. 2 Mental, Neurological, and Substance Use Disorders Box 1.2 Social Determinants of Mental, Neurological, and Substance Use Disorders A range of social determinants influences the risk for MNS disorders (the social causation pathway); and outcome of MNS disorders. In particular, the on the other hand, people living with MNS disor- following factors have been shown to be associated ders drift into poverty during the course of their life with several MNS disorders (Patel and others 2009): through increased health care expenditures, reduced economic productivity associated with the disability 1. Demographic factors, such as age, gender, and of their condition, and stigma and discrimination ethnicity associated with these conditions (the social drift 2. Socioeconomic status: low income, unemploy- pathway). ment, income inequality, low education, and low social support Understanding the vicious cycle of social determi- 3. Neighborhood factors: inadequate housing, over- nants and MNS disorders provides opportunities for crowding, neighborhood violence interventions that target social causation and social 4. Environmental events: natural disasters, war, drift. In relation to social causation, the evidence conflict, climate change, and migration. for the mental health benefits of poverty alleviation 5. Social change associated with changes in income, interventions is mixed but growing. In relation urbanization, and environmental degradation to social drift, the evidence for the individual and household economic benefits of the prevention and The causal mechanisms of the social determinants of treatment of MNS disorders is compelling, and sup- MNS disorders indicate a cyclical pattern. On the one ports the economic argument for scaling up these hand, socioeconomic adversities increase the risk interventions (Lund and others 2011). Inevitably, such an approach does not address a • Second, we address the question of what by reviewing significant number of conditions, for example, mul- the evidence on the effectiveness of specific interven- tiple sclerosis as a neurological disorder and anorexia tions for the prevention and treatment of a selection nervosa as an adult mental disorder. However, the rec- of MNS disorders. ommendations in this volume, particularly regarding • Third, we consider how and where these interventions the delivery of packages for care, could be extended to can be appropriately implemented across a range of other conditions not expressly addressed. In addition, service delivery platforms. some important MNS disorders or concerns are cov- • Fourth, we address the question of how much by ered in companion volumes of DCP3, notably, nicotine examining the cost of scaling up cost-effective inter- dependence, early childhood development, neurological ventions and the case for enhanced service coverage infections, and stroke. and financial protection for MNS disorders. This volume addresses four overall questions and themes (box 1.3): This chapter also considers how some countries have attempted to incorporate this body of evidence • First, we address the question of why MNS disorders into scaled-up programs for MNS disorders. The deserve prioritization by pointing to and reviewing chapter discusses lessons on barriers and strategies the health and economic burden of disease attrib- for how these will need to be addressed for successful utable to MNS disorders. We build on the 2010 scaling-up. estimates of the Global Burden of Diseases, Injuries, The primary focus of the volume—and DCP3 as a and Risk Factors Study (GBD 2010) in two important whole—is on LMICs. We include HICs in the section ways: by examining trends in the burden over time, on global disease burden, and we draw liberally on the and by estimating the additional mortality attribut- concentration of available evidence on intervention able to these disorders. effectiveness from these countries. Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 3 Box 1.3 Key Messages This volume of the third edition of Disease Control 3. Best practice interventions for MNS disorders Priorities addresses mental, neurological, and sub- can be appropriately implemented across a stance use (MNS) disorders. These heterogeneous range of population, community, and health care conditions share several characteristics, not least that platforms. they are among the most neglected of diseases glob- • At the population-level platform of service ally. This volume focuses on those conditions asso- delivery, best practices include legislative and ciated with the greatest burden for which there are regulatory measures to restrict access to means effective and scalable interventions. The key findings of self-harm/suicide and reduce the availabil- and messages of the volume are presented in this ity of and demand for alcohol. overview chapter, as well as an assessment of critical • At the community-level platform, best prac- health system barriers to scaling up evidence-based tices include life skills training in schools to interventions and how to overcome them. build social and emotional competencies in The following are the key messages: children and adolescents. • At the health care platform, which covers self-care, primary health care, and hospital 1. The burden of MNS disorders is large, growing, and care delivery channels, best practices include underestimated. self-management of migraine; diagnosis and The public health burden of MNS disorders, as management of epilepsy, headache, depres- estimated by disability-adjusted life years, is on a sion, anxiety, alcohol and illicit drug use dis- sharp upward trajectory; it increased by 41 percent orders; and continuing care of schizophrenia between 1990 and 2010 and now accounts for one and bipolar disorder in primary care. in every 10 years of lost health globally. Even this 4. Public financing of scaling-up is affordable and sobering statistic is an underestimate, because it increases financial protection. does not explicitly take into consideration either The costs of providing a significantly scaled-up the substantial excess mortality associated with package of specified cost-effective interventions these disorders, estimated in this volume for the for prioritized MNS disorders is estimated at first time, or the enormous social and economic US$3–US$4 per capita of total population per consequences of MNS disorders on affected per- year in low- and lower-middle-income countries, sons, their caregivers, and societies. and at least double that in upper-middle-income 2. Many MNS disorders can be prevented and treated countries. This package includes interventions at effectively. the population, community, and health care lev- A wide variety of effective interventions can pre- els. Since a significant proportion of MNS disor- vent and treat MNS disorders. Although some ders may run a chronic and disabling course and of these interventions are also supported by adversely affect household welfare, it is important evidence of cost-effectiveness, significant gaps that intervention costs are largely met by gov- remain in the availability of evidence to support ernments through increased resource allocation the scaling-up of many interventions. Some of and financial protection measures. Investment of these interventions can have significant impacts public resources in the prevention and treatment on other global health and development prior- of MNS disorders addresses a large and neglected ities. For example, the effective management of public health concern; if targeted wisely, this maternal depression can affect child health out- investment will produce substantial economic comes, and the effective management of conduct as well as health benefits in populations at an disorders in children can affect adult antisocial affordable cost. A policy of moving toward uni- and criminal behavior. versal public finance can lead to a far more box continues next page 4 Mental, Neurological, and Substance Use Disorders Box 1.3 (continued) equitable allocation of public health resources lack of strong and technically sound leadership to across income groups. guide the scaling-up effort, the relatively low levels As many countries and the global community move of demand for care for some of the most common toward a consensus on the need for universal health conditions, the high levels of stigma attached to coverage, this volume provides clear recommenda- many conditions, and the continuing reliance on tions about which interventions should be priori- specialized hospital-based care as the primary deliv- tized, how they can be delivered, and the expected ery platform. cost of scaling up these interventions. We provide Realizing the health gains associated with the inter- evidence from four countries to demonstrate how a ventions recommended in this volume will require combination of political will and increased financial more than financial resources. Committed and commitment to support the delivery of cost-effective sustained efforts will be needed to address these preventive and treatment interventions through barriers. The ultimate goal is massively increasing public systems can lead to significant improvements opportunities for persons with MNS disorders to in service coverage and health outcomes. In most access services without the prospect of discrimi- countries, a range of health system barriers will need nation or impoverishment, and with the hope of to be addressed to achieve these goals, not least the attaining optimal health and social outcomes. WHY MNS DISORDERS MATTER FOR 18.6 percent of total DALYs for individuals aged 15 to GLOBAL HEALTH 49 years, compared with 10.4 percent for all ages com- bined. Within the 15 to 49 years age group, mental and The GBD 2010 identified MNS disorders as significant substance use disorders were the leading contributor to causes of the world’s disease burden (Whiteford and the total burden caused by MNS disorders. For neuro- others 2013). The DCP3 series as a whole uses the Global logical disorders, DALYs were highest in the elderly. Health Estimates of disease burden. This volume also There are important gender differences in the includes data from the 2010 GBD study, which are used in burden of these disorders. Overall, males accounted the burden calculations presented in chapter 3 (Charlson for 48.1 percent and females for 51.9 percent of DALYs and others 2015). The broad patterns conveyed are the for MNS disorders. Males accounted for more DALYs for same across the 2010 GBD study (Whiteford and others mental disorders occurring in childhood, schizophrenia, 2013), the more recent 2013 GBD data (Global Burden substance use disorders, Parkinson’s disease, and of Disease Study 2013 Collaborators 2015), and WHO’s epilepsy; whereas, more DALYs accrued to females for Global Health Estimates (WHO 2014). all other disorders in this group. The relative proportion In chapter 2 in this volume (Whiteford and others of DALYs for MNS disorders to overall disease burden 2015), we investigate trends in the burden caused by was estimated to be 1.6 times higher in HICs (15.5 per- MNS disorders. There was a 41 percent increase in cent of total DALYs) than in LMICs (9.4 percent of total absolute disability-adjusted life years (DALYs) caused by DALYs), largely because of the relatively higher burden MNS disorders between 1990 and 2010, from 182 million of other health conditions, such as infectious and peri- to 258 million DALYs (the proportion of global disease natal diseases, in LMICs. However, because of the larger burden increased from 7.3 to 10.4 percent). With the population of LMICs, absolute DALYs for MNS disor- exception of substance use disorders, which increased ders are higher in LMICs compared with HICs. because of changes in prevalence over time, this increase Data from GBD 2010 on burden caused by pre- was largely caused by population growth and aging. mature mortality may incorrectly lead to the inter- DALYs are constituted of two components: years of pretation that premature death in people with MNS life lost (YLLs) and years lived with disability (YLDs). disorders is inconsequential. This interpretation is due Figure 1.1 summarizes the proportion of all-cause to how causes of deaths are assigned in the International YLLs and YLDs explained by MNS disorders in 2010. Classification of Diseases (ICD) death coding system As a group, MNS disorders were the leading cause of used by GBD 2010. Yet, evidence shows that people with YLDs in the world. In 2010, DALYs for MNS disorders MNS disorders experience a significant reduction in life were highest during early to mid-adulthood, explaining expectancy, with the risk of mortality increasing with Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 5 Figure 1.1 Proportion of Global YLDs and YLLs Attributable to Mental, Neurological, and Substance Use Disorders, 2010 a. YLLs b. YLDs Mental Substance use Neurological disorders Substance use disorders disorders 0.1% disorders 3.9% 1.8% 0.4% Communicable Mental diseases disorders 15.5% 18.9% Injuries Non communicable 5.9% Communicable diseases (excluding diseases MNS disorders) Neurological 43.7% disorders 40.5% 5.6% Non communicable diseases (excluding MNS disorders) Injuries 50.2% 13.5% Additional suicide YLLs attributable to mental and substance use disorders 1.3% Source: Whiteford and others 2015; http://vizhub.healthdata.org/gbd-compare. Note: 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 percent of suicide YLLs or 1.3 percent of total all-cause YLLs (Ferrari and others 2014). the severity of the disorder (Chang and others 2011; be interpreted carefully. Table 1.1 summarizes cause- Lawrence, Hancock, and Kisely 2013; Walker, McGee, specific and excess deaths attributable to each MNS dis- and Druss 2015). order. Comparative risk analyses have also highlighted Therefore, chapter 3 in this volume (Charlson and mental and substance use disorders as significant risk others 2015) explores differences between the GBD factors of premature death from a range of other health 2010 estimates of cause-specific and excess mortality outcomes (Lim and others 2012). For example, an esti- of these disorders, and potential contributors to life mated 60 percent of suicide deaths can be re-attributed expectancy gaps. Although reported YLLs accounted for to mental and substance use disorders, elevating them only 15.3 percent of MNS disorder DALYs, equivalent from the fifth to third leading cause of burden of dis- to 840,000 deaths, natural history models generated by ease (Ferrari and others 2014). These findings strongly DisMod-MR (a disease modeling tool) estimate that suggest the importance of continued assessment of the substantially more deaths are associated with these dis- role MNS disorders play in premature death and as risk orders. Excess deaths associated with major depression factors for other health outcomes. alone were estimated at more than 2.2 million in 2010. The estimates of disease burden do not fully take This figure is significantly higher than other attempts to into account the significant social and economic con- quantify these deaths (Walker, McGee, and Druss 2015), sequences of MNS disorders, not only for affected indi- and indicates a potentially higher degree of mortality viduals and households, but also for communities and associated with MNS disorders than that captured by economies. Notable examples of such impacts include GBD 2010 YLLs. the effects of maternal mental disorders on the well- Since these estimates of excess deaths include deaths being of children, contributing to the intergenerational from causal and non-causal origins, however, they must transmission of ill-health and poverty; the effects of 6 Mental, Neurological, and Substance Use Disorders Table 1.1 Cause-Specific and Excess Deaths Associated with Mental, Neurological, and Substance Use Disorders, Global Burden of Disease Study, 2010 Cause-specific deaths Excess deaths Disorder (uncertainty range) (uncertainty range) Contributors to excess deaths Alzheimer’s disease and 486,000 2,114,000 Lifestyle factors including smoking, other dementias (308,000–590,000) (1,304,000–2,882,000) hypercholesterolemia, high blood pressure, low forced vital capacity; comorbid physical conditions including cardiovascular disease; infectious disease including pneumonia. Epilepsy 178,000 296,000 Underlying conditions including neoplasms, (20,000–222,000) (261,000–331,000) cerebrovascular diseases, and cardiac disease; accident or injury resultant from status epilepticus including drowning and burns. Migraine 0 0 N/A Alcohol use disorders 111,000 1,954,000 Comorbid disease including cancer; mental, (64,000–186,000) (1,910,000–1,997,000) neurological, and substance use disorders; cardiovascular disease; liver and pancreas diseases; epilepsy, injuries; and infectious disease. Opioid dependence 43,000 404,000 Acute toxic effects and overdose; accidental (27,000–68,000) (304,000–499,000) injuries, violence, and suicide; comorbid disease including cardiovascular disease, liver disease, Cocaine dependence 500 96,000 mental disorders, and blood-borne bacterial and viral (200–500)c (60,000–130,000) infections. Amphetamine dependence 500 202,000 (100–300)c (155,000–250,000) Cannabis dependence 0 0 Schizophrenia 20,000 699,000 Suicide and comorbid disease including (17,000–25,000) (504,000–886,000) cardiovascular disease and diabetes. Major depressive disorder 0 2,224,000 Suicide and comorbid disease such as cardiovascular (1,900,000–2,586,000) disease and infectious disease. Anxiety disorders 0 0a Comorbid disease such as cardiovascular disease and neoplasms; intentional and unintentional injuries. Bipolar disorder 0 1,320,000 Comorbid disease such as cardiovascular disease; (1,147,000–1,495,000) causes including intentional injuries/suicide. Disruptive behavioral 0 0b Unintentional injuries including traffic accidents; disorders lifestyle factors such as smoking, binge drinking, and obesity. Autistic spectrum 0 109,000 Accidents, respiratory diseases, and seizures; disorders (96,000–122,000) comorbid conditions, particularly epilepsy and intellectual disability. Source: Whiteford and others 2015. a. In GBD 2010, the anxiety disorders category represents “any” anxiety disorder. Although mortality data are available for individual anxiety disorders, estimates of mortality associated with “any” anxiety disorder required for GBD purposes are unavailable. b. There are currently insufficient data to derive estimates of excess mortality for disruptive behavioral disorders. c. In the GBD 2010 cause of death modeling, the mean value for cocaine and amphetamine use disorders falls outside of the 95% uncertainty interval. This was because the full distribution of 1,000 draws is asymmetric with a long tail, and a small number of high values in the uncertainty distribution pushes the mean above the 97·5 percentile of distribution. Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 7 substance use disorders on criminal behavior and incar- and young adulthood; and dementia late in life. The ceration; and the effects of a range of severe conditions epidemiologies of these disorders share some important on the economic productivity of affected persons and characteristics: with the exception of dementia, the vast family members engaged in caregiving. majority of cases have their onset before age 30 years A recent study estimated that total economic out- and most tend to run a chronic or relapsing course. In put lost to MNS disorders globally was US$8.5 trillion addition, several of the disorders are associated with in 2010, a sum expected to nearly double by 2030 if a other health concerns. For example, injecting drug use concerted response is not mounted (Bloom and others is associated with HIV/AIDS, alcohol use disorders are 2011). A separate study estimated the economic costs associated with road traffic injuries and liver cirrhosis, attributable to alcohol use and alcohol use disorders to depression is associated with cardiovascular disease, and amount to the equivalent of between 1.3 and 3.3 percent maternal depression is associated with child undernu- of gross domestic product (GDP) in a range of high- trition and delayed cognitive development (Prince and and middle-income countries, with over two-thirds of others 2007). the loss represented by productivity losses (Rehm and The evidence on interventions presented in this others 2009). section builds on the work published in DCP2 and its The global cost of dementia in 2010 was estimated findings (Chandra and others 2006; Hyman and others to be US$604 billion, equivalent to 1 percent of global 2006; Rehm and others 2006). The evidence is derived GDP (WHO 2012). In addition, a rising tide of social from various sources: the mhGAP guidelines developed adversities is associated with MNS disorders (box 1.2). by the World Health Organization (WHO) for use in Moreover, large and growing proportions of the global non-specialized health settings, which used the Grading population have been affected by conflict or displace- of Recommendations Assessment, Development and ment because of environmental degradation and climate Evaluation (GRADE) methodology to review the litera- change, which bodes for a grim forecast on the future ture published up to 2009 (Dua and others 2011); other burden of these conditions. recent reviews, where appropriate, such as Strang and Finally, the disease burden estimates do not account others (2012) for illicit drugs; interventions that require for the significant hazards faced by persons with MNS a specialist for delivery but that were not addressed by disorders in relation to the systematic denial of basic mhGAP or DCP2, assessed with GRADE; and a review human rights. These costs range from limited oppor- of all reviews. The review of all reviews includes sys- tunities for education and employment, to torture and tematic reviews and any type of evaluation evidence denial of freedom, sometimes within health care institu- from LMICs published since mhGAP and assessed with tions (Patel, Kleinman, and Saraceno 2012). GRADE. The findings are summarized in table 1.2. Effective Essential Interventions WHAT WORKS? EFFECTIVE INTERVENTIONS FOR THE PREVENTION AND TREATMENT OF A wide variety of effective medicines and psychological and social interventions is available to prevent and treat MNS DISORDERS the range of MNS disorders covered in this volume. This section addresses the evidence on effective inter- As shown in table 1.2, it is possible to identify for this ventions for a subset of MNS disorders selected because group of conditions a set of essential medicines (such as of their contribution to the burden of disease and the antipsychotic, antidepressant, and anti-epileptic medi- availability of cost-effective and scalable interventions. cations) and essential psychosocial interventions (such as The disorders are organized under five broad groups: cognitive behavioral therapy and parent skills training). adult mental disorders (chapter 4), neurological disor- Although there are very few curative interventions for ders (chapter 5), illicit drug use disorders (chapter 6), these disorders, the severity and course of most of them alcohol use disorders (chapter 7), and child mental and can be greatly attenuated by psychosocial treatment or developmental disorders (chapter 8). Self-harm and sui- generic formulations of essential psychotropic medi- cide (chapter 9), which are commonly associated with cines, including in combinations tailored to the needs MNS disorders, are also addressed. of individuals. A small minority of patients with more The selected disorders have their onset across the life severe, refractory, or emergency clinical presentations course: epilepsy, anxiety disorders, autism, and intellec- will require specialist interventions, such as inpatient tual disability in childhood; migraine, depression, psy- care with expert nursing for acute psychosis, modified chotic disorders (schizophrenia and bipolar disorders), electroconvulsive therapy for severe depression, or sur- illicit drug use, and alcohol use disorders in adolescence gery for epilepsy. 8 Mental, Neurological, and Substance Use Disorders Table 1.2 Effective Interventions for the Prevention, Treatment, and Care of Mental, Neurological, and Substance Use Disorders Type of disorder Preventive interventions Drug and physical interventions Psychosocial interventions MENTAL DISORDERS IN ADULTHOOD Schizophrenia Chronic or relapsing condition characterized by Antipsychotic medication*** • Family therapy/support** (5.3% of total MNS delusions, hallucinations, and disturbed behavior • Community-based rehabilitation* DALYs) • Self-help and support groups* Mood and anxiety Group of conditions characterized by somatic, CBT for persons with subthreshold Antidepressant, anxiolytic, mood • CBT*** disorders emotional, cognitive, and behavioral symptoms; symptoms** stabilizer, and antipsychotic • Interpersonal therapy** (41.9% of total MNS bipolar disorder associated with episodes of medication;*** DALYs) elated and depressed mood ECT for severe refractory depression** MENTAL AND DEVELOPMENTAL DISORDERS IN CHILDHOOD AND ADOLESCENCE Conduct disorder Pattern of antisocial behaviors that violate the Life skills education to build social • Parenting skills training*** (2.2% of total MNS basic rights of others or major age-appropriate and emotional well-being and • CBT* DALYs ) societal norms competencies;** parenting skills training;** maternal mental health interventions* Anxiety disorders Excessive or inappropriate fear, with associated Parenting skills training;** • CBT*** (2.3% of total MNS behavioral disturbances that impair functioning maternal mental health DALYs) interventions** Autism Severe impairment in reciprocal social • Parental education and skills (1.6% of total MNS interactions and communication skills, as well training* DALYs) as the presence of restricted and stereotypical • Educational support* behaviors ADHD Neurodevelopmental disorder characterized by Psychosocial stimulation of infants Methylphenidate** • Parenting skills training** (0.2% of total MNS inattention and disorganization, with or without and young children* • Cognitive behavioral therapy** DALYs ) hyperactivity-impulsivity, causing impairment of functioning table continues next page Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 9 10 Table 1.2 Effective Interventions for the Prevention, Treatment, and Care of Mental, Neurological, and Substance Use Disorders (continued) Type of disorder Preventive interventions Drug and physical interventions Psychosocial interventions Intellectual disability Significantly impaired cognitive functioning and Psychosocial stimulation of infants • Parental education and skills (idiopathic) deficits in two or more adaptive behaviors and young children;* training* (0.4% of total MNS perinatal interventions, for • Educational support* Mental, Neurological, and Substance Use Disorders DALYs ) example screening for congenital hypothyroidism;** population-based interventions targeting intellectual disability risk factors (such as reducing maternal alcohol use)* NEUROLOGICAL DISORDERS Migraine Episodic attacks where headache and nausea are Prophylactic drug treatment with Drug treatments, aspirin or one of • Behavioral and cognitive (8.7% of total MNS the most characteristic attack features; headache propranolol or amitriptyline*** several other nonsteroidal anti- interventions* DALYs) lasting for hours to 2–3 days, typically moderate inflammatory drugs*** or severe and likely to be unilateral, pulsating, and aggravated by routine physical activity Epilepsy A brain disorder traditionally defined as the Population-based interventions Standard anti-epileptic medications (6.8% of total MNS occurrence of two unprovoked seizures occurring targeting epilepsy risk factors (phenobarbital, phenytoin, DALYs) more than 24 hours apart with an enduring (preventing head injuries, carbamazepine, valproic acid);*** predisposition to generate further seizures neurocysticercosis prevention)* epilepsy surgery** Dementia A neuropsychiatric syndrome characterized by a Cardiovascular risk factors Cholinesterase inhibitors and • Caregiver education and (4.4% of total MNS combination of progressive cognitive impairment, management (healthy diet, physical memantine for cognitive functions; support*** DALYs) BPSD, and functional difficulties activity, tobacco use cessation)* medications for management of • Behavioral training and BPSD* environmental modifications ** • Interventions to support caregivers of people with dementia** table continues next page Table 1.2 Effective Interventions for the Prevention, Treatment, and Care of Mental, Neurological, and Substance Use Disorders (continued) Type of disorder Preventive interventions Drug and physical interventions Psychosocial interventions SUBSTANCE USE DISORDERS Alcohol use disorders Harmful use is a pattern of alcohol use that Excise taxes*** Naltrexone, acamprosate* • Family support* (6.9% of total MNS causes damage to physical or mental health Restriction on sales** • Motivational enhancement, brief DALYs) Alcohol dependence is a cluster of physiological, Minimum legal age** advice, CBT** behavioral, and cognitive phenomena in which • Screening and brief the use of a substance takes on a much higher Drunk driving countermeasures** interventions*** priority for a given individual than other behaviors Advertising bans* that once had greater value • Self-help groups* Restrictions on density* Opening and closing hours and days of sale** Family interventions* Illicit drug use disorders A pattern of regular use of illicit drugs Psychosocial interventions with Opioid substitution therapy • Self-help groups, psychological (7.8% of total MNS characterized by significantly impaired control primary school children, such as the (methadone, buprenorphine)*** interventions, CBT* DALYs) over use and physiological adaptation to regular Good Behavior Game or Strengthening consumption as indicated by tolerance and Families Program* withdrawal SUICIDE AND SELF-HARM Suicide and self-harm The act of deliberately killing oneself; suicide Policies and legislation to reduce Effective drug interventions for • Social support and psychological (1.47% of GBD; 22.5 attempt refers to any nonfatal suicidal behavior access to the means of suicide (such underlying MNS disorders** therapies for underlying MNS million YLLs or 62.1% and intentional self-inflicted poisoning, injury, or as pesticides)*** Emergency management of disorders, Planned follow-up and of suicide YLLs are self-harm that may or may not have a fatal intent Decriminalization of suicide* poisoning** monitoring of suicide attempters* attributed to mental and or outcome Responsible media reporting of substance use disorders suicide* in 2010) Notes: ADHD = Attention Deficit Hyperactivity Disorder; BPSD = behavioral and psychological symptoms; CBT = cognitive behavioral therapy; DALY = disability-adjusted life year; ECT = electroconvulsive therapy; GBD = Global Burden of Diseases; MNS = mental, neurological, and substance use; YLLs = years of life lost. *** = evidence of cost-effectiveness; ** = strong evidence of effectiveness but not cost-effectiveness; * = modest evidence of effectiveness and either no cost-effectiveness or no evidence of cost-effectiveness. Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 11 Certain preventive interventions that are primarily example, the symptoms associated with depression or intended to target disorders covered in other DCP3 anxiety disorders are commonly interpreted as being volumes, for example, to prevent cardiovascular diseases normative consequences of social adversity, and proven or neurocysticercosis, will also have benefits for disorders biomedical or psychological causal models are rare, covered in this volume, such as dementia and epilepsy, leading to low demand for care and low visibility of the respectively. Conversely, some interventions targeting condition from the view of health policy makers and MNS disorders are also associated with benefits to health providers (Aggarwal and others 2014). It is clear that outcomes for other disorders. Examples include injury these competing views will affect the societal preference prevention as a result of reduced alcohol or drug use or for and acceptability of investment in the wider adop- effective treatment of Attention Deficit Hyperactivity tion of effective interventions for MNS disorders. More Disorder, reduced antisocial behaviors and associated generally, stigma, lack of awareness, and discrimination social consequences as a result of treatment of conduct are major factors behind low levels of political commit- disorders in childhood, improved cardiovascular health ment and the paucity of demand for care for persons as a result of recovery from depression, and enhanced with MNS disorders in many populations (Saraceno and early child development as a result of psychosocial others 2007). stimulation in infancy. Even for those conditions for which there are currently no highly effective treatments for the primary disorder, such as autism and dementia, HOW TO DELIVER EFFECTIVE psychosocial interventions have been shown to be effec- tive in addressing their adverse social consequences and INTERVENTIONS? supporting family caregivers. The implementation of evidence-based interventions for MNS disorders seldom occurs through the delivery of single, vertical interventions. More frequently, these Limited Access to Essential Interventions interventions are delivered via platforms—the level of Despite this evidence, many persons affected by MNS the health or welfare system at which interventions or disorders do not have access to the interventions. In packages can be most appropriately, effectively, and effi- general, severe MNS disorders tend to have higher rates ciently delivered. A specific delivery channel, such as a of contact coverage, while treatment gaps for less visible school or a primary health care center, can be viewed as conditions, such as harmful drinking and depression the vehicle for delivery of a particular intervention on a and anxiety disorders, approach or exceed 90 percent specified platform. Identifying the set of interventions in many populations. Similarly, the coverage rates tend that fall within the realm of a particular delivery channel to be much higher for medicines than for psychosocial or platform is of interest and relevance to decision mak- interventions. Across all disorders, the rates of effec- ers because it enables potential opportunities, synergies, tive coverage are low. Supply-side and demand-side and efficiencies to be identified. It also reflects how barriers play a role in explaining these low coverage resources are often allocated in practice, for example, to rates. The lack of adoption of effective interventions is schools or primary health care services, rather than to often influenced by concerns about financial resources. specific interventions or disorders. This section identi- This issue is being addressed by a mounting evidence fies three broad platforms: population, community, and base demonstrating the effectiveness of the delivery of health care. these interventions by nonspecialist health workers (van There is a fair amount of good evidence from HICs Ginneken and others 2013), as well as their costs and for interventions across these platforms and along the cost-effectiveness (chapter 12 in this volume, Levin and continuum of primary, secondary, and tertiary preven- Chisholm 2015). tion. However, the evidence base for LMICs is far less A related resource constraint concerns the low avail- robust. Recommendations for best practice and good ability of appropriately trained mental health workers. practice interventions for the platforms are shown in Cultural attitudes and beliefs may also pose specific table 1.3. Best practice interventions were identified on barriers. For example, the moral model of addiction sees the basis of evidence for their effectiveness and contex- it as largely a voluntary behavior in which people freely tual acceptability and scalability in LMICs, plus evidence engage in substance use. By contrast, the medical model of their cost-effectiveness at least in HICs. Good practice of addiction recognizes that a minority of users will lose interventions were identified on the basis of sufficient control over their use and develop a mental or physical evidence of their effectiveness in HICs and/or promising disorder—an addiction—that requires specific treat- evidence of their effectiveness in LMICs. The lack of evi- ment if sufferers are to become abstinent. As another dence of cost-effectiveness in LMICs reflects the absence 12 Mental, Neurological, and Substance Use Disorders Table 1.3 Intervention Priorities for Mental, Neurological, and Substance Use Disorders by Delivery Platform Platforms for intervention delivery Health care platforms Target area Population platform Community platform Self-care Primary health care First-level hospital care Specialized care All MNS Awareness campaigns to Training of gatekeepers disorders increase mental health (community workers, police, literacy and address teachers) in early identification stigma and discrimination of priority disorders, provision Legislation on protection of low-intensity psychosocial of human rights of persons support, and referral pathways affected by MNS disorders Self-help and support groups (for example, for alcohol use disorders, epilepsy, parents of children with developmental disorders, and survivors of suicide) Adult mental Child protection laws Workplace stress reduction Physical activity Screening and proactive case Diagnosis and management ECT for severe disorders programs and awareness of Relaxation training finding of psychosis, depression, of acute psychoses or refractory alcohol and drug abuse and anxiety disorders Management of severe depression Education about early symptoms and their Diagnosis and management of maternal depression* Management of management depression (including maternal) Management of depression refractory psychosis and anxiety disorders* and anxiety disorders in with clozapine Web- and smartphone- based psychological Continuing care of people with HIV, and people therapy for depression schizophrenia and bipolar with other NCDs* and anxiety disorders disorder Management of depression and anxiety disorders in people with HIV, with other NCDs* Child Child protection laws Parenting programs in infancy to Web- and smartphone- Screening for developmental Diagnosis of childhood mental and promote early child development based psychological disorders in children mental disorders such as developmental Life skills training in schools therapy for depression Maternal mental health autism and ADHD disorders to build social and emotional and anxiety disorders in interventions Stimulant medication for competencies adolescents severe cases of ADHD Parent skills training for Parenting programs in early and developmental disorders Newborn screening for middle childhood (ages 2-14 Psychological treatment for modifiable risk factors for years) mood, anxiety, ADHD, and intellectual disability Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders Early child enrichment/preschool disruptive behavior disorders* education programs Improve the quality of antenatal and Identification of children with perinatal care to reduce risk factors MNS disorders in schools associated with intellectual disability 13 table continues next page 14 Table 1.3 Intervention Priorities for Mental, Neurological, and Substance Use Disorders by Delivery Platform (continued) Platforms for intervention delivery Health care platforms Target area Population platform Community platform Self-care Primary health care First-level hospital care Specialized care Neurological Policy interventions to Self-managed Diagnosis and management of Diagnosis of dementia Surgery for disorders address the risk factors for treatment of migraine epilepsy and headaches and secondary causes of refractory epilepsy cardio-vascular diseases, Self-identification/ Screening for detection of dementia headache for example, tobacco management of seizure control Interventions to support triggers caregivers of patients with Improved control of Self-management of dementia neurocysticercosis Mental, Neurological, and Substance Use Disorders risk factors for vascular Management of prolonged seizures disease (healthy diet, or status epilepticus physical activity, tobacco use) Alcohol and Regulate the availability Awareness campaigns to reduce Self-monitoring of Screening and brief interventions Management of severe Psychological illicit drug use and demand for alcohol maternal alcohol use during substance use for alcohol use disorders dependence and withdrawal treatments (CBT) disorders (for example, increases pregnancy Opioid substitution therapy for refractory in excise taxes on (methadone and buprenorphine) cases* alcohol products, for opioid dependence advertising bans) Penalize risky behaviors associated with alcohol (enforcement of BAC limits) Suicide and Control the sale and Safer storage of pesticides in Web- and smartphone- Primary health care packages for Treatment of comorbid mood Specialist health self-harm distribution of means the community and farming based treatment for underlying MNS disorders (as and substance use disorder* care packages for of suicide (such as households depression and self – described above)* underlying MNS pesticides) harm Planned follow-up and monitoring of disorders (as Decriminalize suicide suicide attempters* described above) Emergency management of poisoning Note: Red type denotes urgent care; blue type denotes continuing care; black type denotes routine care. Recommendations in bold = best practice; recommendations in normal font = good practice. ADHD = Attention Deficit Hyperactivity Disorder; BAC = blood alcohol concentration; CBT = cognitive behavioral therapy; ECT = electroconvulsive therapy; HIV = human immunodeficiency virus; MNS = mental, neurological, and substance use; NCDs = noncommunicable diseases. *There is no fixed time period for the management of these complex conditions; for example, in the management of depression, some individuals need relatively short periods of engagement (for example, 6-12 months for a single episode) at the one end, while others may need maintenance care for several years (for example, when there is a relapsing course). of evidence rather than the lack of cost-effectiveness for channels: self-management and care, primary health most interventions. care (which includes outreach services in the commu- In addition to bridging the treatment gap for MNS nity), and hospital care (which include MNS specialist disorders by improving access to evidence-based inter- services and other specialist services, such as HIV or ventions, it is imperative to enhance the quality of ser- maternal health care). vice delivery, which together with need and utilization Examples of best or good practice packages for self- make up the concept of effective coverage. The quality of care include the self-management of conditions, such care should not be subservient to the quantity of avail- as migraines, and web-based psychological therapy for able and accessible services, not least since robust quality depression and anxiety disorders, increasingly enabled improvement mechanisms ensure that limited resources by internet- and smartphone-based delivery. are utilized appropriately. Good quality services also At the primary health care level, a range of case- build people’s confidence in care, thereby fueling the finding, detection, and diagnostic measures, as well as demand for and increased utilization of preventive and the psychological and pharmacological management of treatment interventions. such conditions, can be effectively performed. The con- ditions include depression (including maternal depres- sion), anxiety disorders, migraines, and alcohol and Population and Community Platforms illicit drug use disorders, as well as continuing care for Chapter 10 in this volume (Petersen and others 2015) severe disorders such as epilepsy or psychosis. outlines the intervention packages for delivery through The recommended delivery model is collaborative the population and community platforms. Population stepped care, in which patient care is coordinated by platform interventions typically apply to the entire pop- a primary care–based nonspecialist case manager who ulation and mainly revolve around promoting men- carries out a range of tasks including screening, provi- tal health, preventing MNS disorders, and addressing sion of psychosocial interventions, and proactive moni- demand-side barriers. Best practice packages include toring, while working in close liaison with, and acting as legislative and regulatory measures to restrict access a link between the patient, primary care physician, and to means of self-harm/suicide (notably pesticides) and specialist services. A robust evidence base supports the reduce the availability of and demand for alcohol, includ- delivery of psychosocial interventions by appropriately ing increased taxes and advertising bans. Good practice trained and supervised nonspecialist health workers packages include interventions aimed at raising mental (van Ginneken and others 2013) and the collaborative health literacy and reducing stigma and discrimination. stepped care model of delivery (Patel and others 2013). The criminal justice system offers an important channel At the hospital level, first-level hospitals, typically for the delivery of interventions for a range of MNS disor- district hospitals, offer a range of medical care services ders, notably those associated with alcohol and illicit drug focused on providing integrated care for MNS disorders, use, behavior disorders in adolescents, and psychoses. by implementing the same packages as recommended Other preventive and promotion interventions do for the primary care channel. In particular, first-level not require such a populationwide approach. These hospitals offer those services where MNS disorders interventions are best delivered by targeting a group of frequently co-occur, such as maternal health, other people in the community that share a certain character- noncommunicable diseases, and HIV/AIDS (Kaaya and istic or are part of a particular setting, such as children others 2013; Ngo and others 2013; Rahman and others in school. This platform is referred to as the community. 2013). Specialist health care may be offered in first- Best practice packages at the community level include level hospitals or separate specialist hospitals, such as life skills training to build social and emotional com- psychiatric hospitals or de-addiction centers. Specialist petencies in children and adolescents (school-based health care delivery channels focus on the diagnosis programs and programs that target vulnerable children). and management of complex, refractory, and severe Good practice packages at the community level are cases (for example for psychosis, bipolar disorder, or reported in table 1.3. refractory epilepsy); childhood behavioral disorders; dementia; severe alcohol or illicit drug dependence and withdrawal; and severe depression. Health Care Platform A small minority of individuals with MNS disor- Chapter 11 in this volume (Shidhaye, Lund, and ders will require ongoing care in community-based Chisholm 2015) outlines the packages pertaining to residential facilities because of their disability and lack the health care platform through three specific delivery of alternative sources of care and support. The role of Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 15 community outreach teams that can provide variable increased risk of MNS disorders that can overwhelm levels of intensity of care appropriate for individuals’ the local capacity to respond, particularly if the existing needs is also crucial as they provide support to enable infrastructure or health system was already weak or may these individuals to function in an independent way, in have been rendered dysfunctional as a result of the emer- the community, alongside close liaison with general pri- gency situation. There is a heightened need to identify mary care services and other social and criminal justice and allocate resources for providing mental health care services. and psychosocial support in these settings, for those with disorders induced by the emergency and for those with preexisting disorders. International humanitarian Humanitarian Aid and Emergency Response aid and emergency response at the national level can be In humanitarian contexts and emergency affected pop- a channel for rapidly enabling or supporting the avail- ulations, such as those arising from conflicts or natural ability of and access to basic or specialist care. In several disasters, the humanitarian aid and emergency response countries, such emergencies have actually provided channel is yet another channel for delivering much opportunities for systemic change or service reform in needed mental health care. These populations are at an public mental health (WHO 2013b; see also box 1.4). Box 1.4 Country Case Studies on Scaling Up Interventions for Mental, Neurological, and Substance Use Disorders The 686 Project: China (Hong 2012) rates of “creating disturbances” and “causing serious The Central Government Support for the Local accidents.” Management and Treatment of Severe Mental Government investment in the program amounted Illnesses Project was initiated in China in 2004 to ¥ 280 million in 2011. The program’s key inno- with the first financial allotment of ¥ 6.86 million vations were the increase in the availability of (US$829,000 in 2004 dollars). Subsequently it was human resources, including the involvement of referred to as the 686 Project. Modeled on the non-mental-health professionals and their intensive World Health Organization’s (WHO’s) recom- capacity building, which increased the number of mended method for integrating hospital-based and psychiatrists in the country by one-third. community-based mental health services, this pro- gram provides care for a range of severe mental dis- orders through the delivery of a community-based The National Depression Detection and Treatment package by multidisciplinary teams. Program: Chile (MHIN) The National Depression Detection and Treatment The interventions are functionality oriented and Program in Chile is a national mental health pro- provide free outpatient treatment through insurance gram that integrates detection and treatment of coverage (New Rural Cooperative Medical Care depression in primary care. The program is based on system) along with subsidized inpatient treatment scaling up an evidence-based collaborative stepped for poor patients. The program covered 30 percent care intervention in which most patients diag- of the population of China by the end of 2011. nosed with depression are provided medications Evaluation of the program showed improved out- and psychotherapy at primary care clinics, while comes for the more than 280,000 registered patients, only severe cases are referred to specialists. Launched as the proportion of patients with severe mental in 2001, the program operates through a network illnesses who did not suffer a relapse for five years of 500 primary care centers, and presently covers or longer increased from a baseline of 67 percent 50 percent of Chile’s population. to 90 percent, along with large reductions in the box continues next page 16 Mental, Neurological, and Substance Use Disorders Box 1.4 (continued) The program has added many psychologists in pri- In 2011, funding from the Dutch government mary care, amounting to an increase of 344 percent enabled HealthNet TPO and the Burundian between 2003 and 2008. Enrollment of patients in the government to initiate a five-year project aimed program has grown steadily, with around 100,000 to at strengthening health systems. One of the 125,000 patients starting treatment each year from project’s components is the integration of mental 2004 to 2006 and close to 170,000 patients starting health care into primary care using WHO Mental treatment in 2007. Nationwide implementation of Health Gap Action Programme guidelines. The the program has led to greater utilization of health government has established a national commission services by women and the less educated, contribut- for mental health and appropriate steps are being ing to reduced health inequalities. The program’s suc- taken to support the provision of mental health cess can be attributed to the use of an evidence-based care in general hospitals and follow-up within the design that was made available to policy makers, community. teamwork, proactive leadership, strategic alliances across sectors, sustained investment and ring-fencing Suicide Prevention through Pesticide Regulation: new and essential financial resources, program Sri Lanka (Gunnell and others 2007) institutionalization, and sustained development of In Sri Lanka, as well as in other Asian countries, human resources that can implement the program. pesticide self-poisoning is one of the most commonly used methods of suicide. Suicide rates in Sri Lanka Building Back Better: Burundi (WHO 2013a) increased eight-fold from 1950 to 1995, and the Civil war in the last decade of the 20th century and country had the highest rate of suicide worldwide first decade of this century resulted in widespread (approximately 47 per 100,000 population) during massacres and forced migrations and internal this period. A series of policy and legislative actions displacement of around one million individuals around this time reduced the suicide rate by half in Burundi. To address this humanitarian crisis, by 2005. Healthnet Transcultural Psychosocial Organization Gunnell and others (2007) carried out an ecologi- (TPO) started providing mental health services in cal analysis of trends in suicide and risk factors for Burundi during 2000 when the then Ministry of suicide in Sri Lanka during 1975–2005. The analy- Public Health had no mental health policy, plan, or sis suggests that the marked decline in Sri Lanka’s unit, and virtually all the psychiatric services were suicide rate in the mid-1990s coincided with the provided by one psychiatric hospital. Healthnet TPO culmination of a series of legislative activities that first conducted a needs assessment and then built a systematically banned the most highly toxic pesti- network of psychosocial and mental health services cides that had been responsible for the majority of in communities in the national capital, Bujumbura, pesticide deaths in the preceding two decades. The and in seven of the country’s 17 provinces. A new Registrar of Pesticides banned methyl parathion health worker cadre, the psychosocial worker, played and parathion in 1984 and over the following years a pivotal role in delivery of these services. gradually phased out all the remaining Class I (the Considerable progress has been made in the past most toxic) organophosphate pesticides, culminat- decade. The government now supplies essential ing in July 1995 with bans on the remaining Class I psychiatric medications through its national drug pesticides monocrotophos and methamidophos. By distribution center, and outpatient mental health December 1998, endosulfan (a Class II pesticide) clinics are established in several provincial hospitals. was also banned as farmers had substituted Class I From 2000 to 2008, more than 27,000 people were pesticides with endosulfan. helped by newly established mental health and By 2005, suicide rates halved to around 25 per psychosocial services. Between 2006 and 2008, the 100,000 population. This case study underlines the mental health clinics in the provincial hospitals fact that in countries where pesticides are commonly registered almost 10,000 people, who received more used in acts of self-poisoning, regulatory controls than 60,000 consultations. The majority (65 percent) on the sale of the most toxic pesticides may help to were people with epilepsy. reduce the number of suicides. Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 17 HOW MUCH WILL IT COST? MOVING This volume reviews existing cost-effectiveness evidence TOWARD UNIVERSAL HEALTH COVERAGE and new analyses of the distributional and financial pro- tection effects of interventions (box 1.5). FOR MNS DISORDERS For successful and sustainable scale-up of effective Intervention Costs and Cost-Effectiveness interventions and innovative service delivery strategies, such as task-sharing and collaborative care, decision There is a small but growing economic evidence base makers require not only evidence of an intervention’s to inform decision making in LMICs, mainly on the health impact, but also the costs and cost-effectiveness. treatment of specific disorders. Analysis undertaken at Even when cost-effectiveness evidence is available, there the global level by WHO, updated to 2012 values for remains the question of whether or how an intervention DCP3, reveals a marked variation in the cost per DALY might confer wider economic and social benefits on averted, not only between different regions of the world, households or society, such as restored productivity, but also between different disorders and interventions reduced medical impoverishment, or greater equality. (Chisholm and Saxena 2012; Hyman and others 2006). Box 1.5 Economic Evaluation of the Treatment and Prevention of Mental, Neurological, and Substance Use Disorders Economic evaluations aim to inform decision making 4. Assessment of the economic benefits, measured by quantifying the trade-offs between the resource in monetary terms, from investment in a health inputs needed for alternative investments and the intervention and weighing that benefit against its resulting outcomes. Four approaches to economic cost (benefit-cost analysis). This analysis enables evaluation in health are particularly prominent: comparison of the attractiveness of health invest- ments compared with those in other sectors. 1. Assessment of how much of a specific health outcome (for example, depressive episodes or Cost-effectiveness analyses predominate among eco- epileptic seizures averted) can be attained for a nomic evaluations in the care and prevention of particular level of resource input. mental, neurological, and substance use (MNS) 2. Assessment of how much of an aggregate measure disorders. These types of analysis are reviewed in of health (for example, averted deaths, disability, the disorder-specific chapters of the volume and, or quality-adjusted life years) can be attained in a more synthesized format, in chapter 12 (Levin from a particular level of resource inputs applied and Chisholm 2015). This review shows that the to alternative interventions. This approach of economic evidence base for mental health policy cost-effectiveness analysis enables comparison and planning continues to strengthen. Thus, the of the attractiveness of interventions addressing overgeneralized claim that treatment of MNS disor- many different health outcomes (such as tuber- ders is not a cost-effective use of scarce health care culosis or HIV treatment versus prevention of resources can be increasingly debunked. harmful alcohol use or treatment of psychosis). Extended cost-effectiveness analyses remain a fairly 3. Assessment of how much health and financial new evaluation approach developed for Disease risk protection can be attained for a particular level Control Priorities, 3rd edition (DCP3). In this volume, of public sector finance of a particular interven- Chisholm and others (chapter 13) apply extended tion. This approach (extended cost-effectiveness cost-effectiveness analysis to a range of MNS disor- analysis) enables assessment not only of effi- der interventions in Ethiopia and India. The chapter ciency in improving the health of a population, shows that moving toward universal coverage via but also of efficiency in achieving the other major scaled-up provision of publicly financed services goal of a health system (that is, protection of the leads to significant financial protection effects as population from financial risk). well as health gains in the population. 18 Mental, Neurological, and Substance Use Disorders Brief interventions for harmful alcohol use and treat- pose a direct threat to households’ well-being and ment of epilepsy with first-line anti-epileptic medicines economic viability, as a result of private out-of-pocket fall toward the lower (more favorable) end, while com- (OOP) expenditures on health services and goods, as munity-based treatment of schizophrenia and bipolar well as diminished production or income opportunities. disorder with first-generation medications and psycho- Through the application of a newly developed social care fall toward the upper end. Figure 1.2 shows approach to economic evaluation called extended the range for the most cost-effective intervention iden- cost-effectiveness analysis (Verguet, Laxminarayan, and tified for each of these four conditions (for details, see Jamison 2015; see also box 1.5), an effort has been made chapter 12 in this volume, Levin and Chisholm 2015). to identify how scaled-up, community-based public ser- Anderson, Chisholm, and Fuhr (2009) analyze the vices might contribute to greater equality of access and cost-effectiveness of alcohol demand reduction mea- less OOP spending in two distinct settings, India and sures. They estimate that one DALY could be averted Ethiopia. Both countries have recently articulated ambi- for as little as US$200–US$400 through increases in tious plans to enhance mental health service quality and excise taxes on alcoholic beverages, and for US$200– coverage, as well as extend financial protection or health US$1,200 through comprehensive advertising bans or insurance for their citizens. Across these two geograph- reduced availability of retail outlets. Other than that ical settings, it is evident that publicly financing the study, there is hardly any published evidence on the cost- scale-up of mental health service leads to a more equi- effectiveness of population-based or community-level table allocation of public health resources across income strategies in or for LMICs. For example, there remains a groups, with the lowest-income groups benefiting most startling paucity of robust economic studies with which in financial protection. to inform planners and policy makers in LMICs about For example, an extended cost-effectiveness analysis scaled-up efforts to prevent self-harm and suicide, or to was done for schizophrenia treatment in India. The anal- enhance the mental and social development of children ysis shows that public financing of the 70 percent of total through parent skills training. treatment costs incurred by households would remove The combined cost of implementing alcohol control US$140,000 of OOP spending per one million population measures is estimated to range between US$0.10 and at current treatment coverage rates. Public financing of a US$0.30 per capita (Anderson, Chisholm, and Fuhr concerted effort to provide an enhanced level of service 2009; WHO 2011). A new cost analysis carried out for coverage (80 percent) for all segments of the Indian this volume estimates that a school-based, life skills population would result in a more equitable allocation program would cost between US$0.05 and US$0.25 of resources (as shown in figure 1.3, panel a). This effort per capita (Levin and Chisholm 2015). The annual cost would have a clear pro-poor effect (figure 1.3, panel of delivering a defined package of cost-effective inter- b): 30 percent of the total estimated value of insurance ventions for schizophrenia, depression, epilepsy, and (estimated at US$24,582 for a population of one million alcohol use disorders in two WHO subregions (one in persons) is bestowed on the poorest quintile of the popu- Sub-Saharan Africa, the other in South Asia) has been lation, compared with 10 percent for the richest quintile. estimated to be US$3–US$4 per capita (Chisholm and In Ethiopia, where current treatment coverage for psy- Saxena 2012); in HICs and upper-middle-income coun- chosis and other mental disorders is very low (10 percent tries, the cost of such a package is expected to be at least or less), the averted OOP spending arising from a switch double this amount (chapter 12 in this volume, Levin to public finance of treatment costs would also be low. and Chisholm 2015). Only when a substantial increase in service coverage is modeled does the true scale of the private expenditures that would pertain in the absence of publicly financed Financial Risk Protection: Extended Cost- care become apparent. Effectiveness Analysis It is therefore vital for increased financial protection By considering important goals or attributes of health of persons with MNS disorders to go hand in hand systems other than health improvement itself, such as with scaled-up coverage of an essential package of care. equity and financial risk protection, this volume has Improved service access without financial protection for taken some initial steps toward addressing and analyz- persons with MNS disorders will lead to inequitable rates ing the concept of universal health coverage for MNS of service uptake and outcomes, while improved finan- disorders (Chisholm and others 2015). These disorders cial protection without appropriate service scale-up will are chronic and disabling, often go undetected, and are bring little public health gain at all. In short, a concerted, regularly omitted from essential packages of care or multidimensional effort is needed if the move toward insurance schemes. Therefore, these health conditions universal health coverage for MNS disorders is to occur. Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 19 Figure 1.2 Cost-Effectiveness of Selected Interventions for Addressing Mental, Neurological and Substance Use Disorders in Low- income and Middle-income Countries (2012 US$ per DALY averted) a. National study estimates Schizophrenia Facility-based treatment with older (neuroleptic) antipsychotic drug 1,427 (Brazil; Lindner and others 2009) Facility-based psychosocial treatment with neuroleptic antipsychotic drug 1,774 (Nigeria; Gureje and others 2007) Episodic treatment in primary care with newer SSRI drug 1,670 (Thailand; Prukkanone and others 2012) Episodic treatment in primary care with older TCA drug 2,048 (Nigeria; Gureje and others 2007) Maintenance treatment in primary care with newer SSRI: fluoxetine Depression 1,511 (Thailand; Prukkanone and others 2012) Continuation treatment in primary care with newer SSRIs 1,312 (Thailand; Prukkanone and others 2012) Episodic psychosocial treatment in primary care 914 (Thailand; Prukkanone and others 2012) Maintenance psychosocial treatment in primary care 437 (Thailand; Prukkanone and others 2012) Heavy Epilepsy Older anti-epileptic drug in primary care: 50% coverage 279 (Nigeria; Gureje and others 2007) alcohol Drunk driving laws and enforcement via breath testing use 236 (Nigeria; Gureje and others 2007) $1 $10 $100 $1,000 $10,000 b. Regional study estimates 100,000 (US$ per DALY averted, 2012) Cost-effectiveness ratio 10,000 1,000 100 Schizophrenia: Depression: Episodic Epilepsy: Treatment in Alcohol use disorder: Community-based treatment in primary care primary care with older Brief physician advice in treatment with older with (generic) antidepressant anti-epileptic drug primary care antipsychotic medication medication and psychosocial and psychosocial treatment treatment Source: Hyman and others 2006; Chisholm and Saxena 2012; Levin and Chisholm 2015. Note: In panel a, all reported cost-effectiveness estimates have been converted to 2012 US$. In panel b, previously published findings have been converted to 2012 US$ values, based on International Monetary Fund inflation estimates for World Bank reporting regions. Bars show the range in cost-effectiveness for six low- and middle-income world regions: Sub-Saharan Africa, Latin America and the Caribbean, Middle East and North Africa, Europe and Central Asia, South Asia, and East Asia and Pacific. DALY = disability-adjusted life year; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressants. 20 Mental, Neurological, and Substance Use Disorders Figure 1.3 Distribution of Public Spending and Insurance Value of Enhanced Public Finance for Schizophrenia Treatment in India, by Income Quintile a. Distribution of public spending b. Distribution of financial protection benefits 30 8,000 7,000 25 Public health spending (%) 6,000 Value of insurance ($) 20 5,000 15 4,000 3,000 10 2,000 5 1,000 0 0 1 2 3 4 5 1 2 3 4 5 Income quintile Income quintile Current coverage Target coverage Source: Chisholm and others 2015 (chapter 13 in this volume). Note: Results are based on a population of one million people, divided into equal income quintiles of 200,000 persons (quintile 1 has the lowest income and quintile 5 the highest). Monetary values are expressed in 2012 US$. Target coverage for schizophrenia treatment for all income groups is set at 80 percent. Current coverage ranges from 30 percent in the poorest income group to 50 percent in the richest. Panel A shows the distribution of public health spending across income groups before and after the introduction of universal public finance. Panel B shows the distribution of financial protection benefits across income groups resulting from a policy of universal public finance; the value of insurance is per income quintile (each with 200,000 persons). HOW TO SCALE UP? HEALTH SYSTEM disorders. In addition, the following are lacking: techni- BARRIERS AND OPPORTUNITIES cally sound leadership in designing and implementing evidence-based programs; adequate absorptive capacity Despite the need for renewed attention and scaled-up in the existing health care system; competing policy investment, there is relatively little action on addressing priorities and vested interests; and effective agency and MNS disorders in most LMICs. There are several reasons advocacy by affected people. And there is a persisting for this lack of action, perhaps the most important one belief in the importance of hospital-based specialized being the overall lack of policy commitment to MNS models of care, which continue to absorb disproportion- disorders, as is evident from the fact that less than 1 ate amounts of the already meager budgetary allocations percent of the health budget is allocated to mental health for this sector (Saraceno and others 2007). in most LMICs (Saxena and others 2007). Similarly, despite the evidence-based calls to action for scaling up services for almost a decade (Lancet Global Mental Knowledge Gaps Health Group 2007), less than 1 percent of development There is a lack of evidence from LMICs, especially on the assistance for health is devoted to mental health (Gilbert cost-effectiveness of many interventions and the inte- and others 2015). gration of care for MNS disorders in routine health and social care platforms. This lack continues to represent a constraint to investment for many stakeholders, and is Political Will partly a result of low levels of political commitment to Key contributors to the lack of political will and con- this dimension of health through disproportionately less sequently low levels of resource allocation include funding for research. The critical knowledge gaps are the low demand for mental health care interventions, related to implementation science, that is, research to which is in part caused by low levels of mental health bridge the gap between what we know works and how to literacy and high levels of stigma attached to MNS implement it at scale (Collins and others 2011). Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 21 Research that seeks to address the significant knowl- • Investing in research across the translational con- edge gaps on the causes of MNS disorders and the dis- tinuum to improve knowledge on more effective covery of novel interventions is also urgently needed. An interventions and more effective delivery systems, empirical approach to analysis of the impact of macro- including innovative financing options such as rais- economic and structural factors on the burden of MNS ing and diverting income from taxes on unhealthy disorders, such as global conventions on the regulation products (such as alcohol and tobacco) of illicit drugs and climate change, is warranted to guide • Emphasizing the use of low-cost generic medicines evidence-based policy making in the wider context. throughout the health care systems, and reallocating However, these knowledge gaps cannot explain why expenditure on ineffective or low-value interventions, even known cost-effective interventions have not been such as overprescription of benzodiazepines and vita- adopted. mins in primary care. A complicating factor is the limitations of the evi- • Finally, it will be important to embed health indicators dence synthesized in this chapter. In particular, there for MNS disorders within national health information are significant gaps in the evidence in support of some and surveillance systems so that progress and achieve- interventions in LMICs and limited effectiveness of ments can be monitored and evaluated (WHO 2015). the best available interventions for some disorders. To address these barriers, the scaling-up of interventions The WHO Comprehensive Mental Health Action Plan for MNS disorders requires an approach that embraces (Saxena, Funk, and Chisholm 2013) offers a clear road public health principles, systems thinking, and a whole- map for countries at any stage of the journey to scale up. of-government perspective. Reassuringly, several coun- Some regions (such as the Eastern Mediterranean) have tries are now demonstrating how a combination of these adapted this new policy instrument to initiate consul- ingredients can lead to significant increases in the cover- tations with international experts and regional policy age of evidence-based interventions (box 1.4). makers and develop frameworks for action (box 1.6) across all four domains of the plan, along with priority interventions and indicators for evaluation of progress Strategies for Strengthening the Health System (Gater, Saeed, and Rahman 2015). Key strategies for strengthening the health system include the following: TIME TO ACT NOW • Mainstreaming a rights-based perspective throughout MNS disorders account for a substantial proportion of the health system and ensuring health policies, plans, the global disease burden. This burden has increased dra- and laws are updated to be consistent with interna- matically since 1990 and is likely to continue to rise with tional human rights standards and conventions the epidemiological transition from infectious diseases to • Implementing multicomponent initiatives to address noncommunicable diseases, the demographic transition stigma, enhance mental health literacy and demand in LMICs, and the increase in the prevalence of several for care, and mobilize people with the conditions to social determinants associated with these conditions. support one another and be effective advocates Despite the challenges in quantifying causal mortality • Engaging other key sectors concerned with MNS in these disorders, new analyses presented in this volume disorders to improve services, notably the social suggest that the mortality-associated disease burden care, non-governmental organizations, private sector, is very large and was previously underestimated. This criminal justice, education, and indigenous medical volume also summarizes evidence to document effective sectors, as they all have complementary roles. treatment and prevention interventions that are feasible • Providing inpatient care through units in general or to implement across diverse socioeconomic and cultural district hospitals rather than standalone psychiatric settings for a range of priority MNS disorders. A criti- hospitals cally relevant aspect of these disorders is their propensity • Implementing large-scale or national rollouts of to strike early in life, which is a key factor behind their training and supervision programs for nonspecialist large contribution to the global burden of disease. human resource cadres that can perform the roles Populationwide platforms are primarily suited for of case managers for delivery of collaborative care policy-level interventions for promoting mental health, in primary care and other health care platforms to preventing MNS disorders, improving mental health improve treatment coverage literacy, and protecting the human rights of persons • Ensuring the supply of essential medicines at relevant affected by these disorders. The community platform platforms provides opportunities for leveraging non-health 22 Mental, Neurological, and Substance Use Disorders Box 1.6 Proposed Regional Framework to Scale Up Action on Mental Health in the WHO Eastern Mediterranean Region Domain Strategic interventions Proposed indicators Leadership • Establish/update a multisector national policy/ • Country has an operational multisectoral and strategic action plan for mental health in line with national mental health policy or plan in line governance international and regional human rights instruments. with international and regional human rights • Establish a structure, as appropriate for the national instruments. context, to facilitate and monitor implementation of • Country has an updated mental health law in the multisector national policy/strategic action plan. line with international and regional human rights • Review legislation related to mental health in line instruments. with international human rights covenants and • Inclusion of specified priority mental health instruments. conditions in the basic health care packages for • Include defined priority mental health conditions in public and private insurance and reimbursement the basic health delivery package of the government schemes. and social and private insurance reimbursement schemes. • Increase and prioritize budgetary allocations to address the agreed upon service targets and priorities, including providing transitional or bridge funding. Reorientation • Establish mental health services in general hospitals • Proportion of general hospitals that have mental and for outpatient and short-stay inpatient care. health units including inpatient and outpatient units. scaling-up of • Integrate delivery of evidence-based interventions • Proportion of persons with mental health conditions mental health for priority mental health conditions in primary utilizing health services (disaggregated by age, sex, services health care and other priority health programs. diagnosis, and setting). • Enable people with mental health conditions and • Proportion of PHC facilities having regular their families through self-help and community- availability of essential psychotropic medicines. based interventions. • Proportion of PHC facilities with at least one staff • Downsize the existing long-stay mental hospitals trained to deliver nonpharmacological interventions. (in parallel with investment increases in integrated • Proportion of mental health facilities monitored inpatient and general hospitals and supported annually to ensure use of quality and rights residential care in the community).a standards for the protection of human rights of • Embed mental health and psychosocial support in persons with mental health conditions. national emergency preparedness and recovery • Mental health and psychosocial support provision is plans. integrated in the national emergency preparedness • Strengthen the capacity of health professionals plans. for recognition and management of priority mental • Proportion of health care workers trained in health conditions during emergencies. recognition and management of priority mental • Implement evidence-informed interventions for health conditions during emergencies. psychosocial assistance to vulnerable groups. box continues next page Global Priorities for Addressing the Burden of Mental, Neurological, and Substance Use Disorders 23 Box 1.6 (continued) Domain Strategic interventions Proposed indicators Promotion • Integrate recognition and management of maternal • Proportion of community workers trained in and depression and parenting skills training in maternal early recognition and management of maternal prevention and child health programs. depression and providing early childhood care and • Integrate life skills education with a whole-school development and parenting skills to mothers and approach. families. • Reduce access to means of suicide. • Proportion of schools implementing the whole- school approach to promote life skills. • Employ evidence-based methods to improve mental health literacy and reduce stigma. Information, • Integrate the core indicators within the national • Routine data and reports at the national level evidence, and health information systems. available on core set of mental health indicators. research • Enhance the national capacity to undertake • Annual reporting of national data on numbers of prioritized research. deaths by suicide. • Engage stakeholders in research planning, implementation, and dissemination. Source: Gater, Saeed, and Rahman 2015. Note: PHC = primary health care; WHO = World Health Organization. a. Modified by authors. resources for prevention and promotion interventions necessary resources and provide technical leadership. targeting particular groups of people or particular set- As also emphasized in the WHO Mental Health Action tings. The health care interventions primarily comprise Plan, this will and commitment are essential to address generic medicines, brief psychological treatments, and the avoidable toll of suffering caused by MNS disorders, social interventions. Interventions for diverse disorders not least among the poorest people and least resourced can be packaged together to deploy low-cost and widely countries in the world. available human resources in primary health care and This volume presents strong clinical and economic non-health care platforms, with appropriate support evidence to back this investment. Ultimately there must and supervision provided by mental health care profes- also be a moral case for scaling up care for the hundreds of sionals. In settings with a higher level of resources, as is millions of people whose health care needs have been sys- the case in many middle-income countries, specialist tematically neglected and whose basic human rights have platforms offer incremental value in addressing the been routinely denied (Patel, Saraceno, and Kleinman needs of the relatively small proportion of persons with 2006). The time to act on this evidence is therefore now. complex, severe, or refractory clinical presentations. Apart from being effective and feasible and providing NOTE benefits that improve the lifelong trajectories of indi- viduals, many of these interventions are also inexpen- Disclaimer: Dan Chisholm and Tarun Dua are staff members sive to implement and represent a cost-effective use of of the World Health Organization. The authors alone are resources for health. Furthermore, a policy of moving responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of toward universal public finance for MNS disorders can the World Health Organization. be expected to lead to a far more equitable allocation of World Bank Income Classifications as of July 2014 are as public health resources across income groups. With uni- follows, based on estimates of gross national income (GNI) versal public finance, the lowest-income groups would per capita for 2013: benefit most from the value of insurance (used here as a measure of financial protection). • Low-income countries (LICs) = US$1,045 or less • Middle-income countries (MICs) are subdivided: Country case studies show that the most important a) Lower-middle-income = US$1,045 to US$4,125 drivers of change are the political will and commitment b) Upper-middle-income (UMICs) = US$4,126 to US$12,735 of countries and development agencies to allocate the • High-income countries (HICs) = US$12,736 or more. 24 Mental, Neurological, and Substance Use Disorders REFERENCES to Mental and Substance Use Disorders As Risk Factors for Suicide: Findings from the Global Burden of Disease Aggarwal, N. K., M. Balaji, S. Kumar, R. Mohanraj, A. 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Whiteford, Alize J. Ferrari, Louisa Degenhardt, Valery Feigin, and Theo Vos INTRODUCTION substance use disorders. Until recently, there was a poor understanding of the comparative global epidemiology A substantial proportion of the world’s health problems of mental, neurological, and substance use disorders and in high-income countries (HICs) and low- and slower progress compared with other diseases in identify- middle-income countries (LMICs) arises from mental, ing the most cost-effective interventions. To improve the neurological, and substance use disorders (Murray, Vos, health outcomes of people with mental, neurological, and and others 2012; WHO 2008). Treatment rates for substance use disorders in HICs and LMICs, it is impor- these disorders are low, particularly in LMICs, where tant to understand not only the number and distribution treatment gaps of more than 90 percent have been of affected people among countries, but also the way the documented (Wang, Aguilar-Gaxiola, and others 2007). disorders affect their health compared with other diseases. Even in HICs, where rates of treatment are compara- There are many summary measures available to measure tively higher, treatment for mental, neurological, and population health (Alonso, Chatterji, and He 2013; Sassi substance use disorders tends to be provided many years 2006). In this chapter, we focus on the approach in the after the onset of the disorder (Wang, Aguilar-Gaxiola, Global Burden of Disease Study 2010 (GBD 2010) to mea- and others 2007; Wang, Angermeyer, and others 2007). sure disease burden—the most comprehensive measure of population health to date, which combines in one metric the disability and mortality associated with a given disease Global Burden of Mental, Neurological, and (Murray, Vos, and others 2012). Substance Use Disorders The first Global Burden of Disease Study, which Historically, major health policy decisions have been published data on disease burden in 1990 (GBD informed by mortality statistics. Although our under- 1990) (Murray and Lopez 1996), reported that the standing of diseases causing premature mortality has category of mental, neurological, and substance use expanded, the lack of emphasis on morbidity has underval- disorders—a grouping that included depression, selected ued the global impact of prevalent and disabling disorders anxiety disorders, bipolar disorder, schizophrenia, epi- with lower mortality, such as mental, neurological, and lepsy, dementia, Parkinson’s disease, multiple sclerosis, Corresponding author: Harvey A. Whiteford, Queensland Centre for Mental Health Research, University of Queensland, the Park Centre for Mental Health, Wacol, QLD 4076, Australia; h.whiteford@uq.edu.au. 29 and alcohol and drug use disorders—accounted for priority in many LMICs, increasing life expectancies 10.5 percent of the world’s disease burden, as measured due to better reproductive health, childhood nutrition, by disability-adjusted life years (DALYs). The DALY is a and control of communicable diseases meant that more health metric that captures the nonfatal component of people in 2010 were living to ages where mental, neuro- the disease burden as years lived with disability (YLDs), logical, and substance use disorders were most prevalent and the fatal component as years of life lost (YLLs) to (Whiteford, Degenhardt, and others 2013). premature mortality (Murray and Lopez 1996). GBD In GBD 2010, the burden of mental and substance use 1990 showed that five of the top 10 causes of disability— disorders was estimated separately from that of neuro- making up more than 25 percent of global YLDs for logical disorders, such as dementia, Parkinson’s disease, 1990—belonged to the category of mental, neurological, and epilepsy. This approach enabled us to investigate and substance use disorders (Murray and Lopez 1996). more comprehensively the differences in the epidemiol- In its update of burden estimates for 2000–05, the World ogy and burden between these groups of disorders com- Health Organization (WHO) assigned 31.7 percent of pared with previous GBD studies. Mental and substance all YLDs to mental, neurological, and substance use use disorders were among the leading causes of disease conditions; the five main contributors of this burden burden in 2010. They were responsible for 7.4 percent of were depression (11.8 percent), alcohol use disorders global DALYs and 22.9 percent of global YLDs, making (3.3 percent), schizophrenia (2.8 percent), bipolar disorder them the fifth-leading cause of DALYs and the leading (2.4 percent), and dementia (1.6 percent) (WHO 2008). cause of YLDs (Whiteford, Degenhardt, and others 2013). Neurological disorders explained 3.0 percent of global DALYs and 5.6 percent of global YLDs (Murray, Global Burden of Disease Study 2010 Vos, and others 2012; Vos and others 2012). In this chapter we present findings from GBD 2010. The The overarching findings of the study for all 291 dis- GBD 2010 estimated the burden for 291 diseases and eases and injuries have been presented (Lim and others injuries and 67 risk factors and was the first comprehen- 2012; Lozano and others 2012; Murray, Ezzati, and oth- sive re-analysis of the burden since GBD 1990 (Lim and ers 2012; Murray, Vos, and others 2012; Salomon and others 2012; Lozano and others 2012; Murray, Vos, and others 2012; Vos and others 2012), as have the GBD others 2012; Salomon and others 2012; Vos and others 2010 results for mental and substance use disorders 2012; Wang and others 2012). GBD 2010 estimated bur- (Degenhardt, Whiteford, and others 2013; Whiteford, den for three main cause groups: Degenhardt, and others 2013). This chapter presents GBD 2010 burden estimates of mental, neurological, and sub- • Communicable diseases: infectious or transmissible stance use disorders as a group. Specifically, we quantify diseases the global disease burden attributable to mental, neuro- • Noncommunicable diseases: noninfectious or non logical, and substance use disorders and explore variations transmissible diseases in burden by disorder type, age, gender, year, and region. • Injuries (accidental or intentional). This approach provides background and context for chapter 3 in this volume (Charlson and others 2015), The study included a complete epidemiological reas- which responds to the lack of deaths and fatal burden sessment of these communicable and noncommunica- estimated by GBD 2010 for mental, neurological, and ble diseases and injuries across 187 countries; 21 world substance use disorders. Most important, this chapter for regions; males and females; estimated burden for 1990, the first time presents GBD 2010 burden of disease esti- 2005, and 2010; and 20 age groups. Rather than rely on mates at the aggregated level of mental, neurological, and a selective sample of data points as previous GBD studies substance use disorders. Analysis of burden estimates at had, burden estimates were based on a systematic review this aggregated level is important from the clinical and of the literature to obtain all available epidemiological population health perspectives, given that the organiza- data. The estimates were also derived through the use of tion of services in many LMICs does not separate neuro- new statistical methods to model the epidemiological data, logical disorders from mental disorders, something seen quantify disability, adjust for comorbidity between dis- as a progression of Western medical subspecialization. eases, and propagate uncertainty to final burden estimates (Murray, Vos, and others 2012; Vos and others 2012). GBD 2010 highlighted a shift in burden from com- METHODOLOGY municable to noncommunicable diseases and from YLLs Annex 2A summarizes the mental, neurological, and to YLDs (Murray, Vos, and others 2012; Vos and others substance use disorders investigated in GBD 2010 and 2012). Although communicable diseases remain a health describes how the YLDs, YLLs, and DALYs for each 30 Mental, Neurological, and Substance Use Disorders disorder were estimated. More detailed information BURDEN OF MENTAL, NEUROLOGICAL, AND about the input data and methods can be accessed SUBSTANCE USE DISORDERS elsewhere (Baxter and others 2013; Baxter and oth- ers 2014a; Baxter and others 2014b; Degenhardt and Mental, neurological, and substance use disorders others 2011; Degenhardt, Baxter, and others 2014; accounted for 258 million DALYs in 2010, which was Degenhardt, Charlson, and others 2014; Degenhardt, equivalent to 10.4 percent of total all-cause DALYs. Ferrari, and others 2013; Degenhardt, Whiteford, and Within mental, neurological, and substance use disorders, others 2013; Erskine and others 2014; Ferrari, Baxter, mental disorders accounted for the highest proportion of and Whiteford 2010; Ferrari and others 2013a; Ferrari DALYs (56.7 percent), followed by neurological disorders and others 2013b; Saha and others 2005; Whiteford, (28.6 percent) and substance use disorders (14.7 percent). Degenhardt, and others 2013; Whiteford, Ferrari, and For all three groups of disorders, DALYs occurred across others 2013). the lifespan (figure 2.1); however, there was a peak in early To allow for comparability in measurement, the adulthood (between ages 20 and 30 years) for mental definitions of dementia and mental and substance use and substance use disorders compared with neurological disorders used for GBD 2010 were restricted to diag- disorders, where DALYs were highest in the elderly. nostic classifications provided in the Diagnostic and Absolute DALYs for mental, neurological, and Statistical Manual of Mental Disorders (APA 2000) and substance use disorders increased by 41 percent between the International Classification of Diseases (ICD-10) 1990 and 2010, from 182 million to 258 million DALYs. (WHO 1992). The epilepsy definition was based on With the exception of substance use disorders, where ICD-10 (WHO 1992). For each disorder, YLDs and YLLs age-standardized DALY rates for opioid, cocaine, and were summed to estimate DALYs. For disorders where amphetamine dependence increased over time, the there were insufficient data to estimate YLLs, YLDs were increase in absolute DALYs for the other disorders was equated with DALYs. Uncertainty was estimated at all largely caused by changes in population growth and stages of the analysis through microsimulation methods aging. Table 2.1 summarizes the age-standardized DALY and propagated to the final burden estimates. YLDs, rates for 1990 and 2010. YLLs, and DALYs in this chapter are presented for 1990 Table 2.2 summarizes the DALYs assigned to each and 2010 at the following levels: mental, neurological, and substance use disorder in 2010. These disorders as a group ranked as the third- • Global leading cause of DALYs (explaining 10.4 percent of • Disaggregated by disorder type, age, gender, and DALYs), after cardiovascular and circulatory diseases year (explaining 11.9 percent of DALYs), and diarrhea, lower • Disaggregated by the seven superregion groups in GBD 2010: East Asia and Pacific, Eastern Europe and Figure 2.1 DALYs Attributable to Mental, Neurological, and Central Asia, high-income regions (North America, Substance Use Disorders, by Age, 2010 Australasia, Western Europe, high-income Asia Pacific, and southern Latin America), Latin America DALYs (Absolute numbers in 100,000s) 300 and the Caribbean, the Middle East and North Africa, South Asia, and Sub-Saharan Africa 250 • Disaggregated by developed and developing regions. 200 The terms developed and developing regions are 150 used here rather than HICs and LMICs for consistency 100 with the presentation of the GBD 2010 estimates. The classification of countries into regions and regions into 50 superregions was based on geographical proximity and 0 epidemiological likeness in cause of death patterns 28 27 ys 64 ys ys 4 10 9 15 14 20 19 25 24 30 29 35 34 40 9 45 44 50 49 55 54 60 59 65 64 70 69 75 74 9 + 1– 5– –3 –7 80 7– 6 da –3 da da – – – – – – – – – – – – (Murray, Vos, and others 2012; Vos and others 2012). 0– Whiteford, Degenhardt, and others (2013) provide a list of all countries in each region and superregions. Where Age group (in days or years) age-standardized DALY rates are presented, these were Mental disorders Neurological disorders estimated using direct standardization to the global stan- Substance use disorders dard population that WHO proposed in 2001 (http:// Source: http://vizhub.healthdata.org/gbd-compare. www.who.int/healthinfo/paper31.pdf). Note: DALYs = disability-adjusted life years. Global Burden of Mental, Neurological, and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010 31 Table 2.1 Age-Standardized DALY Rates Attributable to Mental, Neurological, and Substance Use Disorders, 1990 and 2010 Age-standardized DALY rates (per 100,000) Male Female Disorder 1990 2010 1990 2010 Mental disorders Major depressive disorder 694.8 689.9 1,171.7 1,161.2 Dysthymia 135.3 135.8 189.7 190.0 Bipolar disorder 172.0 172.1 204.6 204.8 Schizophrenia 230.7 223.0 187.8 180.6 Anxiety disorders 274.3 273.0 508.9 510.3 Eating disorders 4.4 3.9 47.6 59.5 Autism 85.1 85.8 29.5 29.6 Asperger’s syndrome 85.2 85.0 20.3 20.3 Attention-deficit hyperactivity disorder 10.8 10.6 3.1 3.1 Conduct disorder 111.9 113.3 47.0 47.6 Idiopathic intellectual disability 25.3 17.7 18.2 11.9 Other mental and behavioral disorders 25.5 23.3 21.5 20.8 Neurological disorders Alzheimer’s disease and other dementias 125.7 155.5 153.7 178.6 Parkinson’s disease 32.7 36.6 23.2 23.3 Epilepsy 261.6 269.3 226.0 232.9 Multiple sclerosis 16.3 12.3 23.7 19.8 Migraine 233.1 236.6 405.9 415.8 Tension-type headache 24.1 24.0 28.3 28.3 Other neurological disorders 228.0 259.9 200.0 266.7 Substance use disorders Alcohol use disordersa 431.0 409.9 117.2 106.0 Opioid dependence 139.0 184.4 63.8 78.4 Cocaine dependence 22.5 22.0 10.3 9.7 Amphetamine dependence 45.4 47.3 26.9 27.6 Cannabis dependence 38.8 36.7 22.3 21.3 Other drug use disorders 83.7 97.0 44.6 47.9 Source: http://vizhub.healthdata.org/gbd-compare/. Note: DALY = disability-adjusted life year. a. Alcohol use disorders include alcohol dependence and fetal alcohol syndrome. respiratory infections, meningitis, and other common Overall, in 2010, 124 million mental, neurological, infectious diseases (explaining 11.4 percent of DALYs). and substance use DALYs occurred among males and Major depressive disorder was responsible for the high- 134 million among females. Figure 2.2 shows DALY rates est proportion of mental, neurological, and substance for each mental, neurological, and substance use disorder use disorder DALYs (24.5 percent); attention-deficit by gender. Females accounted for more DALYs for most hyperactivity disorder was responsible for the lowest of the mental and neurological disorders, except for (0.2 percent). mental disorders occurring in childhood, schizophrenia, 32 Mental, Neurological, and Substance Use Disorders Table 2.2 DALYs Attributable to Mental, Neurological, and Substance Use Disorders, 2010 Absolute DALYs (to Proportion of total (all- Proportion of mental, neurological, and Disorder the nearest 100,000) cause) DALYs (%) substance use disorder DALYs (%) Mental disorders Major depressive disorder 63,200,000 2.5 24.5 Dysthymia 11,100,000 0.4 4.3 Bipolar disorder 12,900,000 0.5 5.0 Schizophrenia 13,600,000 0.5 5.3 Anxiety disorders 26,800,000 1.1 10.4 Eating disorders 2,200,000 0.1 0.9 Autism 4,000,000 0.2 1.6 Asperger’s syndrome 3,700,000 0.1 1.4 Attention-deficit hyperactivity disorder 500,000 0.02 0.2 Conduct disorder 5,800,000 0.2 2.2 Idiopathic intellectual disability 1,000,000 0.04 0.4 Other mental disorders 1,500,000 0.1 0.6 Subtotal 146,300,000 5.9 56.7 Neurological disorders Alzheimer’s disease and other 11,400,000 0.5 4.4 dementias Parkinson’s disease 1,900,000 0.1 0.7 Epilepsy 17,400,000 0.7 6.8 Multiple sclerosis 1,100,000 0.04 0.4 Migraine 22,400,000 0.9 8.7 Tension-type headache 1,800,000 0.1 0.7 Other neurological disorders 17,900,000 0.7 6.9 Subtotal 73,900,000 3.0 28.6 Substance use disorders Alcohol use disordersa 17,700,000 0.7 6.9 Opioid dependence 9,200,000 0.4 3.6 Cocaine dependence 1,100,000 0.04 0.4 Amphetamine dependence 2,600,000 0.1 1.0 Cannabis dependence 2,100,000 0.1 0.8 Other drug use disorders 5,100,000 0.2 2.0 Subtotal 37,800,000 1.5 14.7 Source: http://vizhub.healthdata.org/gbd-compare/. Note: DALYs = disability-adjusted life years. DALYs were aggregated across all country, gender, and age groups for 2010. a. Alcohol use disorders include alcohol dependence and fetal alcohol syndrome. Parkinson’s disease, and epilepsy, where males accounted in 2010 by the GBD 2010 superregion groupings and for more DALYs. Males also accounted for more DALYs by developed and developing world regions. Overall, than females in all substance use disorders. the burden of these disorders as age-standardized rates Figure 2.3 shows the burden attributable to mental, was approximately 1.6 times higher in developed regions neurological, and substance use disorders as a group (explaining 15.5 percent of total DALYs) compared Global Burden of Mental, Neurological, and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010 33 Figure 2.2 Age-Standardized DALY Rates Attributable to Individual Mental, Neurological, and Substance Use Disorders, by Gender, 2010 Other mental disorders Idiopathic intellectual disability Conduct disorder Attention-deficit hyperactivity disorder Asperger‘s syndrome Autism Eating disorders Anxiety disorders Bipolar disorder Dysthymia Major depressive disorder Other drug use disorders Disorders Cannabis dependence Amphetamine dependence Cocaine dependence Opioid dependence Alcohol use disordersa Schizophrenia Other neurological disorders Tension-type headache Migraine Multiple sclerosis Epilepsy Parkinson‘s disease Alzheimer‘s disease 0 200 400 600 800 1,000 1,200 1,400 DALYs (age-standardized rates per 100,000) Female Male Source: http://vizhub.healthdata.org/gbd-compare/. Note: DALY = disability-adjusted life year. a. Alcohol use disorders include alcohol dependence and fetal alcohol syndrome. 34 Mental, Neurological, and Substance Use Disorders with developing regions (explaining 9.4 percent of Figure 2.3 Age-Standardized DALY Rates Attributable to Mental, total DALYs). When disaggregated by GBD superregions, Neurological, and Substance Use Disorders, by Region, 2010 the burden of mental, neurological, and substance use DALYs (age-standardized rates per 100,000) disorders was highest in Eastern Europe and Central 3,000 Asia and lowest in East Asia and Pacific. Mental disor- 2,500 ders maintained the highest proportion of DALYs in all superregions; the greatest variation in DALYs occurred 2,000 within substance use disorders, where DALYs were almost three times higher in Eastern Europe and Central Asia, 1,500 compared with Sub-Saharan Africa, where DALYs were 1,000 lowest. Figure 2.4 illustrates the decomposition of global 500 burden by YLDs and YLLs for the overall categories of communicable diseases, noncommunicable diseases, 0 e ia a and injuries. Noncommunicable diseases explained a a sia ific an ing ed om ric ric As be hA ac lop lop Af Af inc l rib tra dP large proportion of YLDs and YLLs in 2010. Within this n ve ve ut th gh ra Ca en So an De De or ha Hi dC dN he group, mental, neurological, and substance use disorders sia Sa dt an an tA b- an Su pe were responsible for 28.5 percent of all YLDs, making st as ica Ea ro E Eu er le them the leading cause of YLDs worldwide. Am idd rn ste M tin In comparison, mental, neurological, and substance Ea La use disorders contributed to only 2.3 percent of YLLs. Region Deaths and YLLs could be assigned to a mental, neu- Mental disorders Neurological disorders Substance use disorders rological, or substance use disorder only when the dis- order was considered as a direct cause of death in the Source: http://vizhub.healthdata.org/gbd-compare/. ICD-10 cause-of-death directory. Using this approach, Note: DALY = disability-adjusted life year. DALYs were disaggregated by GBD 2010’s seven superregion groups—East Asia and Pacific, Eastern Europe and Central Asia, high-income regions the majority of excess deaths in individuals with a mental (North America, Australasia, Western Europe, high-income Asia Pacific, and southern Latin disorder, in particular, were coded to the direct physical America), Latin America and the Caribbean, the Middle East and North Africa, South Asia, and cause of death (for example, suicide deaths were coded Sub-Saharan Africa—and by developed and developing regions. Figure 2.4 Proportion of Global YLDs and YLLs Attributable to Mental, Neurological, and Substance Use Disorders, 2010 a. YLLs b. YLDs Mental disorders Neurological disorders Substance use disorders Substance use disorders 0.1% 1.8% 0.4% 3.9% Communicable Mental diseases disorders 15.5% 18.9% Injuries Noncommunicable 5.9% Communicable diseases (excluding diseases MNS disorders) Neurological disorders 43.7% 5.6% 40.5% Noncommunicable diseases (excluding MNS disorders) Injuries 50.2% 13.5% Source: http://vizhub.healthdata.org/gbd-compare/. Note: MNS = mental, neurological, and substance use; YLLs = years of life lost; YLDs = years lived with disability. Global Burden of Mental, Neurological, and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010 35 under injuries as self-harm) rather than to the disorder. GBD studies (Murray and Acharya 1997) recognizes An analysis of excess mortality in individuals with men- and attempts to incorporate the social preference for tal, neurological, and substance use disorders and the avoiding health loss in young adults. In spite of the implications for burden of disease estimates is presented absence of age weighting in the GBD 2010 estimates, in chapter 3 in this volume (Charlson and others 2015). the peak impact of mental, neurological, and substance use disorders in early adulthood remained and demon- strated the ubiquitous effect of these disorders at a time IMPLICATIONS OF THE GBD 2010 FINDINGS of life when individuals are starting to make significant FOR MENTAL, NEUROLOGICAL, AND social and economic contributions to their families and societies. The peak in the total burden of mental, neuro- SUBSTANCE USE DISORDERS logical, and substance use disorders was found in young Mental, neurological, and substance use disorders are a adults. However, unlike many chronic diseases, there is a leading cause of the disease burden worldwide, substan- significant burden in children, lending further evidence tially contributing to health loss in individuals of all ages, to the importance of early intervention strategies for from developed and developing regions. mental, neurological, and substance use disorders. In GBD 2010, the differences in DALYs between men- The presentation of burden estimates by age in GBD tal, neurological, and substance use disorders were guided 2010 facilitates the selection and tailoring of intervention by differences in the prevalence, death, and disability strategies for mental, neurological, and substance use weights associated with each disorder. The input data that disorders. For instance, it allows us to identify the ages at were used to estimate burden are presented in greater which interventions would be most beneficial. Historically, detail elsewhere (Baxter and others 2015; Baxter and oth- mental, neurological, and substance use disorders occur- ers 2014a; Baxter and others 2014b; Degenhardt, Baxter, ring in childhood have not been well represented in and others 2014; Degenhardt, Charlson, and others 2014; burden of disease analyses. GBD 2010 was the first study Degenhardt, Ferrari, and others 2013; Erskine and others to estimate the burden associated with childhood mental 2013; Ferrari and others 2013a; Ferrari and others 2013b; disorders like autism, Asperger’s disorder, attention-deficit Saha and others 2005). Mental disorders, such as anxiety hyperactivity disorder, and conduct disorder. For coun- and depressive disorders, were associated with high levels tries such as those in Sub-Saharan Africa, where children of prevalence and disability. In comparison, schizophre- constitute 40 percent of the population (UN 2011), these nia was associated with low prevalence but high levels of findings highlight the need for prevention and treat- disability; an acute state of schizophrenia obtained the ment services targeted to children and adolescents. The highest disability weight in GBD 2010. The same was availability of such services is often more sporadic than true for opioid dependence, which, although it had lower that of adult services. In addition, the high burden of prevalence in comparison with other substance use disor- neurological disorders in elderly persons emphasizes the ders like cannabis dependence, was associated with high need for the development and implementation of more disability and death. Migraine, in contrast, was associated effective prevention strategies for these disorders, espe- with high levels of prevalence but low disability. cially given the worldwide aging of the population, as well Analysis of burden estimates across time illustrated as the need for equitable health care resource allocation how population growth and a changing age profile for people affected by neurological disorders. between 1990 and 2010 produced a shift in the global The GBD 2010 burden estimates also underlined disease burden from communicable to noncommunica- the extent of the challenge faced by health systems in ble diseases and from YLLs to YLDs (Murray, Vos, and developed and developing regions as a result of mental, others 2012). With improvements in infant and mater- neurological, and substance use disorders. Mental dis- nal health and declining rates of mortality caused by order DALYs are highest in the Middle East and North infectious diseases, particularly in developing regions, Africa, substance use disorder DALYs are highest in more people are now living to the age where noncom- Eastern Europe and Central Asia, and neurological dis- municable diseases such as mental, neurological, and order DALYs are highest in South Asia. These regional substance use disorders are most prevalent. This demo- differences are driven by the global distribution of graphic and epidemiological transition is contributing disorder prevalence and, in some instances, deaths. to a rise in the absolute burden of mental, neurological, Analysis of GBD 2010 prevalence data for mental and substance use disorders (Whiteford, Degenhardt, disorders highlighted the effect of conflict status on and others 2013). the estimates. The prevalence of major depressive dis- Although not adopted in GBD 2010, the use of age order and anxiety disorders was highest in countries weighting in many economic analyses and in earlier with a history of conflict or war, many of which are in 36 Mental, Neurological, and Substance Use Disorders the Middle East and North Africa (Baxter and others the current health status with a theoretical minimum 2014b; Ferrari and others 2013a). risk exposure, in this case, the counterfactual status of The prevalence of opioid and cannabis depen- the absence of mental, neurological, and substance use dence was highest in Australasia and Western Europe disorders in the population. The use of this method to (Degenhardt, Charlson, and others 2014; Degenhardt, estimate the additional burden due to mental and sub- Ferrari, and others 2013). Cocaine dependence was stance use disorders as risk factors for suicide showed highest in the North America, high-income, and south- that these disorders could account for approximately ern Latin America. Although there was less regional 60 percent of suicide YLLs in GBD 2010; this would have variation in the prevalence of amphetamine dependence, increased the overall burden of mental and substance the rates were highest in Southeast Asia and Australasia use disorders in 2010 from 7.4 percent to 8.3 percent of (Degenhardt, Baxter, and others 2014). The largest con- global DALYs (Ferrari and others 2014). Chapter 3 in tributor of deaths and YLLs for drug use disorders was this volume (Charlson and others 2015) explores this opioid dependence, with particularly high proportions issue further and presents an analysis of excess mortality of deaths caused by opioid dependence occurring in the in individuals with mental, neurological, and substance North America high-income region, Eastern Europe, use disorders and the implications of this for burden of and southern Sub-Saharan Africa. disease estimates. In many Eastern European and Sub-Saharan African countries, access to interventions found to be effective in reducing the risk of mortality from opioid dependence— LIMITATIONS OF GBD 2010 AND DIRECTIONS such as opioid substitution therapy, needle and syringe programs, and HIV treatment for those who are HIV- FOR FUTURE RESEARCH positive—is limited. Access to these interventions in Although it represents the most comprehensive the North America High-income region varies subna- assessment of the burden due to mental, neurological, tionally, with insufficient data to determine access rates and substance use disorders to date, not all elements of at the national level (Degenhardt, Charlson, and others the burden were captured in GBD 2010. By focusing on 2014). Prevalence and deaths attributable to Alzheimer’s health loss, the burden in GBD 2010 does not extend disease were highest in North America, high-income to welfare loss; hence, it does not capture all the con- Western Europe, and Australasia. In contrast, preva- sequences of mental, neurological, and substance use lence and deaths attributable to epilepsy were highest disorders for families or societies. For a more complete in Sub-Saharan Africa. The geographic differences in picture of the burden imposed by mental, neurological, the burden of such neurological disorders should be and substance use disorders, future research should focus used to inform research priorities and evidence-based, on quantifying the associated welfare losses. region-specific service delivery and health care planning. Disability weights in GBD 2010 were derived by sur- Effective interventions have been identified for men- veying the general population (rather than by clinicians, tal, neurological, and substance use disorders and are as in previous GBD studies), with the aim of better described in the following chapters. capturing the societal view of health loss. Nevertheless, YLDs explained a larger proportion of the burden adequately encompassing the complexity of health states due to mental, neurological, and substance use disor- that represent mental, neurological, and substance use ders compared with YLLs. To estimate YLLs, GBD 2010 disorders within the survey was challenging; the extent followed the ICD-10 cause-of-death categories, whereby to which the GBD 2010 disability weights entirely deaths can only be assigned to a given condition when it reflected the associated health loss is an important area is considered a direct cause of death. This approach can for further research. only account for some of the excess deaths attributable Furthermore, the established definitions of mental, to mental, neurological, and substance use disorders, neurological, and substance use disorders used in the given that deaths will also be coded to the direct physical study may not be sensitive to non-Western presentations cause of death. For instance, ischemic heart disease or of these disorders, which may have led to an underes- suicide deaths occurring as a result of major depressive timation of burden in developing regions. Although disorder will be coded to cardiovascular disease or inju- these disorders exist in all countries, cultures influence ries rather than to major depressive disorder. their development and presentation. The predominantly The additional burden attributable to mental, Western-based definitions of mental, neurological, and neurological, and substance use disorders as a risk factor substance use disorders can be in conflict with cultural for other health outcomes can be investigated through contexts (Jorm 2006), leading to challenges in assem- comparative risk assessment analysis, which compares bling data on global epidemiology. For example, some Global Burden of Mental, Neurological, and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010 37 languages do not have the words to describe concepts societies. Definitions of mental, neurological, and sub- such as “sadness” or “depression” consistent with how stance use disorders and the subsequent quantification of they are described in Western countries. Explanations disability may not be fully representative of non-Western for the onset and progression of mental, neurological, presentations of these disorders. Further research into the and substance use disorders may be explained through cross-cultural presentations of these disorders is required mechanisms such the presence of spirits or curses, rather for a more comprehensive analysis of burden. than as medical disorders (Jorm 2006). Epidemiological surveys in many LMICs tend to cap- ture somatic manifestations of disorders such as depres- ANNEX sion and anxiety, which may not be as relevant to other The annex to this chapter is as follows. It is available at countries and cultures (Cheng 2001; Whiteford, Ferrari, http://www.dcp-3.org/mentalhealth. and others 2013; Yang and Link 2009). In their survey of mental disorders in China, Phillips and others (2009) • Annex 2A. Global Burden of Mental, Neurological, concluded that some cases of minor depression were and Substance Use Disorders: An Analysis from the likely misdiagnosed cases of major depressive disorder, Global Burden of Disease Study 2010 given that standard diagnostic criteria were not sensitive to cross-cultural presentations of this disorder. A task for upcoming GBD analyses will be to explore the extent to NOTE which certain disorders are misdiagnosed as other men- tal or physical disorders in developing countries and the This chapter was previously published in an article by consequence on burden. H. A. Whiteford, A. J. Ferrari, L. Degenhardt, V. Feigin, and T. Vos, entitled “The Global Burden of Mental, Neurological, Finally, regular updating of burden of disease esti- and Substance Use Disorders: An Analysis for the Global Burden mates, using the most up-to-date epidemiological data of Disease Study 2010.” PLoS ONE, 2015: 10 (2): e0116820. and burden estimation methodology is important. After doi:10.1371/journal.pone.0116820. http://www.ncbi.nlm.nih GBD 2010 was published, the Institute for Health .gov/pmc/articles/PMC4320057/pdf/pone.0116820.pdf. Metrics and Evaluation at the University of Washington endeavored to make available yearly updates of burden of disease estimates. The Global Burden of Disease Study REFERENCES 2013 (GBD 2013) published in 2015 was the first of these Alonso, J., S. Chatterji, and Y. He, eds. 2013. The Burdens updates (GBD 2013 DALYs Hale Collaborators 2015). of Mental Disorders: Global Perspectives from the WHO Although high-level findings were largely consistent World Mental Health Surveys. 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Link. 2009. “Comparing Diagnostic World Health Organization’s World Mental Health Survey Methods for Mental Disorders in China.” The Lancet 373 Initiative.” World Psychiatry 6 (3): 177–85. (9680): 2002–04. 40 Mental, Neurological, and Substance Use Disorders Chapter 3 Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 Fiona J. Charlson, Amanda J. Baxter, Tarun Dua, Louisa Degenhardt, Harvey A. Whiteford, and Theo Vos INTRODUCTION disorders (Chesney, Goodwin, and Fazel 2014). Excess mortality in people with epilepsy is reported to be two- Findings from the Global Burden of Disease Study to three-fold higher than that of the general population, 2010 (GBD 2010) have reinforced the understanding with an increased risk up to six-fold higher in LMICs of the significant impact that mental, neurological, (Diop and others 2005). A significant proportion of and substance use disorders have on population health these deaths is preventable (Diop and others 2005; Jette (Murray and others 2012; Whiteford and others 2013). and Trevathan 2014). One key finding was the health transition from commu- There are multiple causes for lower life expectancy in nicable to noncommunicable diseases across all regions. people with mental disorders (Chang and others 2011; This transition was particularly evident in low- and Crump and others 2013; Lawrence, Hancock, and Kisely middle-income countries (LMICs) (Murray and others 2013). Self-harm is an important cause of death, but 2012), where the proportion of burden attributable to the majority of premature deaths are caused by chronic noncommunicable disease increased from 36 percent in physical disease, particularly ischemic heart disease 1990 to 49 percent in 2010, compared with an increase (IHD), stroke, type II diabetes, respiratory diseases, and from 80 percent to 83 percent in high-income countries cancer (Crump and others 2013; Lawrence, Hancock, (HICs) (IHME 2013). and Kisely 2013). Dementia is an independent risk GBD 2010 estimates that the majority of disease factor for premature death; and patients with physical burden caused by mental, neurological, and substance impairment, inactivity, and medical comorbidities are at use disorders is from nonfatal health loss; only increased risk (Park and others 2014). 15 percent of the total burden is from mortality in In many HICs, the life expectancy gap between those years of life lost (YLLs) (IHME 2013). This finding may with mental disorders and the general population is erroneously lead to the interpretation that premature widening. The general population enjoys a longer life, death in people with mental, neurological, and sub- while the lifespan for those with mental, neurological, stance use disorders is inconsequential. A recent review and substance use disorders remains significantly lower has shown higher mortality risks than the general pop- and unchanged (Lawrence, Hancock, and Kisely 2013). ulation for a range of mental disorders, with a standard- Information on the extent and causes of premature mor- ized mortality ratio (SMR) as high as 14.7 for opioid use tality in people with mental, neurological, and substance Corresponding author: Fiona J. Charlson, University of Queensland, School of Public Health, Herston, Queensland, Australia; fiona_charlson@qcmhr.uq.edu.au. 41 use disorders in LMICs is sparse, but these groups underlying causes of death—for example, suicide as a are understood to experience reduced life expectancy, direct result of major depressive disorder—and likely although causes of death may vary across regions. underestimates the true number of deaths attributable to This chapter explores the cause-specific and excess a particular disorder. However, the estimation of excess mortality of individual mental, neurological, and sub- mortality using natural history models often includes stance use disorders estimated by GBD 2010 and dis- deaths from causal and noncausal origins and likely cusses the results. We present the additional burden that overestimates the true number of deaths attributable to can be attributed to these disorders, using GBD results a particular disorder. The challenge is to parse out causal for comparative risk assessments (CRAs) assessing men- contributions to mortality, beyond those already iden- tal, neurological, and substance use disorders as risk fac- tified as cause-specific, from the effects of confounders. tors for other health outcomes. We focus on the following The quantification of the burden attributable to risk mental, neurological, and substance use disorders: factors requires approaches such as CRA, which is now an integral part of the GBD studies. The fundamental • Mental disorders, including schizophrenia, major approach is to calculate the proportion of deaths or dis- depressive disorder, anxiety disorders, bipolar dis- ease burden caused by specific risk factors—for example, order, autistic disorder, and disruptive behavioral lung cancer caused by tobacco smoking—while holding disorders (attention-deficit hyperactivity disorder all other independent factors constant. A counterfactual [ADHD] and conduct disorder [CD]) approach is used to compare the burden associated to • Substance use disorders, including alcohol use disor- an outcome with the amount expected in a hypotheti- ders (alcohol dependence and fetal alcohol syndrome) cal situation of ideal risk factor exposure, for example, and opioid, cocaine, cannabis, and amphetamine zero prevalence. This provides a consistent method dependence for estimating the changes in population health when • Neurological disorders, including dementia, epilepsy, decreasing or increasing the level of exposure to risk and migraine. factors (Lim and others 2012). For the purposes of GBD 2010, countries were grouped into 21 regions and 7 super-regions based on geographic proximity and levels of child and adult mor- METHODOLOGY tality (IHME 2014; Murray and others 2012). Regions were further grouped into developed and developing Years of Life Lost and Cause of Death categories using the GBD 2010 method. Details of coun- The GBD uses YLLs to quantify the fatal burden due tries in each region and super-region can be found on to a given disease or injury (Lozano and others 2012). the Institute for Health Metrics and Evaluation (IHME) YLLs are computed by multiplying the number of website (IHME 2014). deaths attributable to a particular disease at each age by The mortality associated with a disease can be quan- a standard life expectancy at that age. The standard life tified using two different, yet complementary, methods expectancy represents the normative goal for survival; employed as part of the GBD analyses. First, cause-specific for GBD 2010, it was computed based on the lowest mortality draws on vital registration systems and verbal recorded death rates in any age group in countries with autopsy studies that identify deaths attributed to a single populations greater than five million (Salomon and underlying cause using the International Classification others 2012). of Diseases (ICD) death coding system. Second, GBD Cause-specific death estimates in GBD 2010 were creates natural history models of disease, drawing on produced from available cause-of-death data for 187 a range of epidemiological inputs, which ultimately countries from 1980 to 2010. Data sources included vital provide epidemiological estimates for parameters registration, verbal autopsy, mortality surveillance, cen- including excess mortality—that is, the all-cause mortal- suses, surveys, hospitals, police records, and mortuaries ity rate in a population with the disorder above the all- (Lozano and others 2012). Because cause-of-death data cause mortality rate observed in a population without are often not available or are subject to substantial prob- the disorder. By definition, the estimates of excess deaths lems of comparability, a method of modeling cause- include cause-specific deaths. of-death estimates and trends was developed. Cause Although arbitrary, the ICD conventions are a neces- of Death Ensemble Modeling (CODEm) was used for sary attempt to deal with the multi-causal nature of mor- all mental, neurological, and substance use disorders tality and avoid the double-counting of deaths. Despite (Foreman and others 2012). CODEm uses four families the system’s clear strengths, cause-specific mortality of statistical models testing a large set of different mod- estimated via the ICD obscures the contribution of other els using different permutations of covariates. Model 42 Mental, Neurological, and Substance Use Disorders ensembles were developed from these component Excess Mortality from Natural History Models models, and model performance was assessed with The GBD 2010 methods for developing a natural history rigorous out-of-sample testing of prediction error and model of disease using DisMod-MR are discussed in the coverage of 95 percent uncertainty intervals. Details chapter 2 in this volume (Whiteford and others 2015) and relating to CODEm and the method for how these in detail elsewhere (Ferrari and others 2013; Murray and models were used in calculating YLLs are described in others 2012). DisMod-MR is a Bayesian meta-regression detail elsewhere (Foreman and others 2012; Lozano and tool that estimates a generalized negative binomial others 2012). model for all epidemiological data (Murray and others Ultimately, YLLs for GBD 2010 were computed 2012). The primary role of this modeling is to derive from cause-specific mortality estimates for only 7 of internally consistent models of prevalence that are used the 15 mental, neurological, and substance use disorders to produce burden of disease estimates—years lived investigated in this chapter (Lozano and others 2012): with disability (YLDs) and disability-adjusted life years • Dementia (DALYs). The models also provide estimates of other • Epilepsy epidemiological parameters, utilizing the relationship • Schizophrenia described in figure 3.1 (Murray and others 2012). Excess • Alcohol use disorders (including alcohol dependence mortality estimates for mental, neurological, and sub- and fetal alcohol syndrome) stance use disorders were made available through this • Opioid dependence process. • Amphetamine dependence Cause-specific mortality estimated using ICD coding • Cocaine dependence. rules does not consider the contribution of underlying causes of death. However, estimates of excess deaths pro- The justification for this selection lies in the rules of duced by DisMod-MR include deaths from causal and the ICD, which specify that the recorded cause of death noncausal origins and therefore overestimate the true should be the primary or direct cause of death, resulting number of deaths attributable to a particular disorder. in several important disorders being absent from the In this chapter, although we compare GBD 2010 esti- ICD cause-of-death list (Lim and others 2012; WHO mates from both of these data sources and discuss the 1993). For example, a person dying from endocarditis discrepancies between the two, caution should be exer- caused by injecting drug use is likely to have the cause cised in interpreting the excess mortality data attribut- of death coded to endocarditis rather than the substance able to mental, neurological, and substance use disorders. use disorder. Figure 3.1 Generic Disease Model Deaths in the general General population population from causes other than disease New cases (incidence) Cases recovered (remission) Deaths in people with disease attributable to other causes Deaths attributable to disease Existing cases (prevalence) (cause-specific mortality) Source: Adapted from Barendregt and others 2003, figure 1. Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 43 Counterfactual Burden and Comparative Risk is evident, the comparatively smaller contribution of Assessment several mental disorders is a finding that requires further Using counterfactual analysis, the effect of a risk factor explanation. can be quantified by comparing the burden associ- Examination of age-standardized YLL rates indicates ated with an outcome with the amount expected in large variations across the seven GBD 2010 geograph- a hypothetical situation of ideal risk factor exposure. ical super-regions, primarily because of differences in Prince and others (2007) have summarized the evi- patterns of alcohol use disorders, drug dependence, and dence where causal relationships between mental and mental and neurological disorder prevalence. Several substance use disorders and other health outcomes have regions have significant deviations from the global aver- been proposed. In GBD 2010, reviews were conducted to age YLL rates (figure 3.3). assess the strength of evidence for mental, neurological, In figure 3.3, amphetamine and cocaine depen- and substance use disorders as independent risk factors dence have been aggregated under psychostimulant for other health outcomes (Charlson and others 2011; dependence. Details of which countries are in each super- Degenhardt and Hall 2012; Degenhardt, Hall, and oth- region can be found on the IHME website (IHME 2014). ers 2009; Rehm, Baliunas, and others 2010). Risk factor In 2010, YLL rates were highest in Sub-Saharan studies were identified through systematic searches Africa (604 YLLs per 100,000 population) and Central/ of published and unpublished data, and information Eastern Europe and Central Asia (593 YLLs per 100,000); on effect sizes and study characteristics was extracted the causes of these high fatal burden estimates vary and collated (Charlson and others 2013; Degenhardt, considerably (figure 3.3). In Sub-Saharan Africa, the Whiteford, and others 2013; Ferrari and others 2014). YLL burden was driven by epilepsy, which accounted Data were metasynthesized to calculate relative risks for 511 YLLs per 100,000 population. This rate is four- (RR) for mental and alcohol use disorders (the expo- fold higher than the global average and approximately sures) as risk factors for other health outcomes. These 85 percent of all YLLs attributed to mental, neurological, included mental and substance use disorders collectively and substance use disorders in the region. Sub-Saharan as risk factors for suicide, alcohol use as a risk factor for Africa has comparatively lower YLL rates for substance a range of health outcomes, and injecting drug use as a use disorders; however, illicit drug dependence YLLs risk factor for blood-borne viruses. The RR was applied increased by 3.0 percent from 1990 to 2010, almost to prevalence distributions of the specific exposures by double the average global increase and the highest of gender and age group for each region to derive pop- all regions. The Middle East and North Africa follows ulation attributable fractions (PAFs). The additional with a 2.6 percent increase (Degenhardt, Whiteford, and burden (YLLs and YLDs) attributable to mental, neu- others 2013). rological, and substance use disorders is the product of The high fatal burden in Central/Eastern Europe and the PAFs and the burden for the health outcome as esti- Central Asia was largely caused by deaths attributed to mated in GBD 2010. More detail on the calculation of alcohol use disorders. These disorders accounted for 331 PAFs in GBD 2010 is provided by Lim and others (2012). YLLs per 100,000 population, compared with a global average of 57 YLLs per 100,000 population. High mor- tality caused by illicit drug use disorders also contributed MORTALITY AND MENTAL, NEUROLOGICAL, to the YLL rate in Central/Eastern Europe and Central AND SUBSTANCE USE DISORDERS Asia, with all substance use disorders together explaining 73 percent of YLLs in the region. Causal Mortality and Years of Life Lost Substance use disorders also explained a high pro- The seven disorders for which YLLs were estimated in portion of total mental, neurological, and substance GBD 2010 were directly responsible for 840,000 deaths use YLLs in Latin America and the Caribbean and in in 2010, or approximately 20 million YLLs (figure 3.2). HICs. In Latin America and the Caribbean, substance Online annex 3A further summarizes the YLLs allocated use disorders accounted for 142 YLLs per 100,000 pop- to mental, neurological, and substance use disorders by ulation (54 percent of the region’s mental, neurological, disorder, age, and gender. The YLLs attributable to each and substance use YLLs). In HICs, substance use dis- disorder as a proportion of total YLLs caused by men- orders accounted for 151 YLLs per 100,000 population tal, neurological, and substance use disorders highlight (49 percent of the region’s mental, neurological, and several key points. Globally, epilepsy contributed the substance use YLLs). Countries in East Asia and Pacific greatest proportion of YLLs within this group, followed exhibit very low YLL rates across all mental, neuro- by dementia. Although the impact of substance use logical, and substance use disorders, with little change disorders, specifically alcohol and opioid dependence, observed between 1990 and 2010. 44 Mental, Neurological, and Substance Use Disorders Globally, neurological disorders accounted for Figure 3.2 Age-Standardized YLL Rates by Disorder, as a Proportion 58 percent of all mental, neurological, and substance of Global YLL Rates for Mental, Neurological, and Substance Use use disorder YLLs in men, and 81 percent in women. Disorders, per 100,000 Population, 2010 Substance use disorders explained 39 percent of YLLs Schizophrenia, in men and 16 percent in women. The contribution of 3.1% schizophrenia to total mental, neurological, and sub- stance use disorder YLLs was similar for both genders, at 3 percent each. Differences in YLL patterns between the genders were influenced in part by the differing contribution to YLLs Alcohol use disorders, Psychostimulant of substance use disorders compared with neurological dependence, 19.9% disorders across regions. Where substance use disorders 0.2% dominated YLLs, their higher prevalence in men drove Epilepsy, Opioid 43.4% up the overall YLL rates in men, compared with women. dependence, Interestingly, the gender differential was not stable across 10% regions: in Central/Eastern Europe and Central Asia, there was a smaller gender difference in the proportion Dementia, of YLLs caused by alcohol use disorders (61 percent of 23.6% mental, neurological, and alcohol use disorder YLLs in men and 40 percent in women). A much larger gender differential exists in Latin America and the Caribbean, where 57 percent of YLLs were caused by alcohol use Source: IHME 2013. disorders in men and 15 percent in women. The gender Note: For the purposes of this graph, amphetamine and cocaine dependence have been aggregated under psychostimulant dependence. The individual disorder proportions are amphetamine dependence differential for YLLs caused by alcohol use disorders was (0.1 percent) and cocaine dependence (0.1 percent). YLLs = years of life lost. comparatively smaller in HICs: 28 percent of YLLs in men and 13 percent of YLLs in women, compared with the global mean of 27 percent and 9 percent, for men and women, respectively. Figure 3.3 Age-Standardized YLL Rates for Mental, Neurological, and In those regions where neurological disorders con- Substance Use Disorders, by GBD 2010 Super-Region and Disorder, tribute the greater proportion of YLLs, the gender differ- per 100,000 Population, 2010 ential was considerably smaller, as shown in figure 3.4. In Sub-Saharan Africa, for example, where epilepsy deaths 700 Age-standardized YLL rate (per 100,000) were very high, there was less of a gender difference: 600 epilepsy explained 84 percent of mental, neurological, and substance use disorder YLLs in men, compared 500 with 86 percent in women. In South Asia, epilepsy con- 400 tributed 60 percent of YLLs in men and 65 percent in women. 300 200 Excess Mortality from a Natural History Model 100 The GBD cause-of-death modeling translates to a rela- tively small YLL burden attributable to mental, neurolog- 0 Sa As , ia b- al pe ca st nia n es al ea As ical, and substance use disorders; however, to conclude Ea fri Su entr Euro as ntri ha ia ob ea ibb nA h le Gl Oc t u ou idd ar ra e co C n that mental disorders are not associated with premature ra r d dC S te M an Ce com an nd ia death would be misleading. The mental disorders for l/E As aa ica -in er gh ric t nt as which cause-specific deaths and YLLs were estimated in Am Hi Af t/E rth tin as GBD 2010 were schizophrenia and anorexia nervosa (the No he La ut So latter is not considered in this chapter). Several other mental disorders, such as major depressive disorder and Epilepsy Psychostimulant use disorders Dementia Opioid use disorders Alcohol use disorders Schizophrenia bipolar disorder, exhibit significant and documented excess mortality (Baxter, Page, and Whiteford 2011; Source: IHME 2013. Roshanaei-Moghaddam and Katon 2009) (table 3.1). Note: GBD = Global Burden of Disease; YLL = year of life lost. Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 45 Figure 3.4 Age-Standardized YLL Rates for Mental, Neurological, and These were not included in the estimated cause-specific Substance Use Disorders, by GBD 2010 Super-Region and Gender, deaths and YLLs, because the method for cause-of-death per 100,000 Population, 2010 estimation, where death counts are used to calculate YLLs, can only be attributed to the primary ICD cause 1,000 of death. 900 800 Examination of excess mortality derived from natu- YLL rates (per 100,000) 700 ral history models of disease allows for a better appre- 600 ciation of the contribution of underlying diseases to 500 poor health outcomes. There were five disorders for 400 which sufficient evidence of excess all-cause mortality 300 could not be found in the literature—anxiety disorders, 200 ADHD, CD, cannabis dependence, and migraine—and 100 no estimations of excess mortality were made. 0 Sa l As e, ca Ce rn E s a sia ia n al e p ric ea fri an ob as ntri Su tra ro ha ia hA Mental Disorders Af ibb nA ce u Gl ou ut th dO ar ra ec So or dC Figure 3.5 shows the estimated number of cause-specific te an dN m n an co sia l/E an b- and excess deaths for each of the five mental disorders, ica -in tA ra st gh er nt as Ea Am Hi Ce with estimated excess mortality by age and uncertainty t/E le idd tin as he bounds. Inspection of excess deaths suggests that schizo- La M ut So phrenia, major depressive disorder, bipolar disorder, and Males Females autistic disorder are all associated with significant pre- Source: IHME 2013. mature mortality not reflected in YLL calculations. This Note: GBD = Global Burden of Disease; YLL = year of life lost. work should be interpreted with caution, given that not Table 3.1 Presence of Cause-Specific Mortality and Excess Mortality Attributed to Mental, Neurological, and Substance Use Disorders in GBD 2010 Cause-specific mortality attributed Excess mortality attributed Disorders to disorders in GBD 2010 to disorders in GBD 2010 Mental disorders Major depressive disorder No Yes Anxiety disorders No No Schizophrenia Yes Yes Bipolar disorders No Yes Disruptive behavioral disorders: ADHD and CD No No Autistic disorder No Yes Substance use disorders Alcohol use disordersa Yes Yes Opioid dependence Yes Yes Cannabis dependence No No Amphetamine dependence Yes Yes Cocaine dependence Yes Yes Neurological disorders Epilepsy Yes Yes Migraine No No Dementia Yes Yes Note: ADHD = attention-deficit hyperactivity disorder; CD = conduct disorder; GBD = Global Burden of Disease study. a. Cause-specific deaths for alcohol use disorders include those from alcohol dependence and fetal alcohol syndrome; differentially, excess deaths represent those from alcohol dependence only. 46 Mental, Neurological, and Substance Use Disorders Figure 3.5 Cause-Specific and Excess Deaths Attributed to Mental Disorders, by Age, with 95 percent Uncertainty, 2010 a. Schizophrenia b. Bipolar disorder 0.25 0.45 0.40 0.20 0.35 Global deaths (millions) Global deaths (millions) 0.30 0.15 0.25 0.20 0.10 0.15 0.05 0.10 0.05 0 0 + + 4 4 9 4 4 9 4 9 4 4 4 4 4 9 4 4 4 4 4 4 75 75 –2 –6 –1 –5 1– 5– –1 –1 –3 –4 –5 –7 1– 5– –1 –2 –3 –4 –6 –7 20 55 15 45 10 15 25 35 45 65 10 20 25 35 55 65 Age Age c. Autistic disorder d. Major depressive disorder 0.025 0.35 0.30 0.020 Global deaths (millions) 0.25 Global deaths (millions) 0.015 0.20 0.010 0.15 0.10 0.005 0.05 0 0 + + 4 4 4 4 9 25 4 4 4 4 9 4 9 4 9 4 75 85 –1 –3 –3 1– 5– –2 –4 –5 –7 –1 –7 –1 –6 5– –5 10 25 20 35 45 65 15 65 15 55 45 Age Age Upper UI (excess deaths) Mean excess deaths Lower UI (excess deaths) Upper UI (CoD counts) Mean CoD counts Lower UI (CoD counts) Source: IHME 2013. Note: CoD = cause-specific deaths; UI = uncertainty interval. Disruptive behavioral disorders (attention-deficit hyperactivity disorder and conduct disorder) and anxiety are not shown, as cause-specific and excess mortality were not estimated. all the excess deaths estimated by DisMod-MR will be depression is linked to higher rates of coronary heart causally attributable to the disorder. A complex interplay disease (Charlson and others 2011). Lifestyle risk factors of risk factors will typically contribute to the high rates and the use of medications in the treatment of some of all-cause mortality in people with mental disorders. mental disorders contribute to higher morbidity and Mental disorders can directly impact the risk of mortality rates through increased risk of obesity and chronic disease through underlying biochemical mecha- metabolic dysfunction. Smoking rates are significantly nisms (Stapelberg and others 2011). For example, major higher in people with mental disorders (Lasser and Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 47 others 2000); this group experiences disproportionate attributable to their condition: a strong and consistent tobacco-related harm. relationship between schizophrenia and higher death Despite their increased exposure to chronic disease rates has been shown; the onset of schizophrenia gen- risk factors, people with mental disorders have inequita- erally precedes the physical health condition causally ble access to health care, with less opportunity for met- associated with their death; and plausible biological abolic risk factor screening (Crump and others 2013) pathways exist through the side effects of medication and early cancer detection (Kisely, Campbell, and Wang and unhealthy behaviors directly related to the condition 2009) and lower rates of common prescriptions and (Laursen, Nordentoft, and Mortensen 2014). Although procedures (Kisely and others 2007; Laursen and others poverty may be a confounding factor, with schizophre- 2009), even in HICs. nia more prevalent in low socioeconomic populations that tend to experience poorer health outcomes, evi- Schizophrenia. People with schizophrenia have well- dence indicates that people with schizophrenia move documented premature mortality (Laursen 2011), but to these populations because of the impact of their very few YLLs in GBD 2010. Although schizophrenia disorder, such as difficulty in securing education and is one of the few mental disorders with cause-specific employment because of cognitive and social problems deaths permissible by ICD, the number of cause-specific (Lambert, Velakoulis, and Pantelis 2003). Accordingly, deaths globally (approximately 20,000) is noticeably schizophrenia can be the mediating factor for poorer lower compared with the number of all-cause deaths socioeconomic and health outcomes. (approximately 700,000) ascribed by the disorder’s natural history. Bipolar Disorder. Approximately 1.3 million excess Research from HICs suggests that men with schizo- deaths were estimated in the natural history model of phrenia die about 15 years earlier than men without bipolar disorder. However, in contrast to schizophrenia, schizophrenia; women with schizophrenia die, on aver- no cause-specific deaths are attributed to the disorder. age, 12 years earlier than women without schizophrenia The natural history of the disease suggests that bipolar (Crump and others 2013; Lawrence, Hancock, and Kisely disorder is associated with more excess deaths globally 2013). The majority of these deaths is due to chronic than schizophrenia. Research from the United Kingdom disease; cardiovascular disease accounts for more than suggests that the excess mortality rates in schizophrenia 33 percent of all premature deaths in those with schizo- and bipolar disorder are comparable (Chang and others phrenia (Crump and others 2013; Lawrence, Hancock, 2011); the higher number of deaths is likely explained and Kisely 2013). Suicide, homicide, and accidents by the higher population prevalence of bipolar disorders account for less than 15 percent of excess deaths (Crump (58.9 million cases in 2010, compared with 23.8 million and others 2013; Lawrence, Hancock, and Kisely 2013). cases for schizophrenia) (Whiteford and others 2013). The side effects of antipsychotic medications, par- An estimated 80 percent of premature deaths in peo- ticularly weight gain and impaired glucose tolerance, ple with bipolar disorder is caused by physical disease, increase the risk of excess mortality in people regularly almost 50 percent of which is cardiovascular disease taking these medications. Despite concerns over the side (Westman and others 2013). Unnatural causes account effects of antipsychotic medication, the lack of antipsy- for nearly 20 percent of premature deaths (Westman and chotic treatment has been linked with higher all-cause others 2013). mortality rates (hazard ratio [HR] 1.45; 95% confidence interval [CI], 1.20-1.76), with the highest risks attrib- Autistic Disorder. GBD 2010 estimated that more than uted to suicide (HR 2.07; 95% CI, 0.73-5.87) and cancer 100,000 excess deaths were caused by autistic disorder. (HR 1.94; 95% CI, 1.13-3.32) (Crump and others 2013). There is clear evidence of premature mortality in Research shows that although cancer-related death rates the natural history of autistic disorder, despite lack are higher in this group, people with schizophrenia are of disorder-specific deaths registered using ICD codes. at lower risk of developing cancer (Grinshpoon and People with developmental disorders are at twice the risk others 2005). High mortality rates therefore likely reflect of premature death compared with the general population inadequate and unequal access to health care and lower (Mouridsen and others 2008). There are several causes of rates of diagnostic screening. Multiple medications and elevated death rates in autistic disorder, including acci- discontinuation of medication also appear to increase dents, respiratory diseases, and seizures (Mouridsen and the risk of all-cause death (Haukka and others 2008; others 2008; Shavelle, Strauss, and Pickett 2001). Autism Joukamaa and others 2006). spectrum disorders are highly comorbid, with a range of Research suggests that the majority of excess mor- potentially life-limiting physical conditions, including tality in people with schizophrenia could be directly epilepsy and chromosomal disorders such as fragile X 48 Mental, Neurological, and Substance Use Disorders syndrome (Gillberg and Billstedt 2000), which suggest burns, poisoning, and fractures (Rowe, Maughan, and shared underlying pathophysiology. Without an identi- Goodman 2004). Adolescents and young adults with fied temporal sequence in onset of these comorbid disor- inattention disorders are more likely to be involved in ders and a plausible biological pathway, it is likely that the traffic accidents (Jerome, Segal, and Habinski 2006). causal relationship between autistic disorder and elevated Adults who were identified with behavioral disorders in mortality may be due more to the presence of comorbid childhood are at higher risk of cigarette smoking, binge conditions rather than autistic disorder itself (Bilder and drinking, and obesity (von Stumm and others 2011). others 2013; Lee and others 2008). Despite the strong evidence of an association between childhood behavioral disorders and poorer Major Depressive Disorder. No deaths were coded to health outcomes, insufficient data are available to model major depressive disorder in GBD 2010, because the the natural history of disease; accordingly, no estimates disorder was absent from the list of ICD cause-of-death quantify excess mortality in this group at the population codes. Natural history models of major depressive dis- level. However, it is likely that a significant proportion order suggest that more than 2.2 million excess deaths of excess mortality is causally attributable to these occurred in this group. In GBD 2010, no YLLs and no conditions. There is not only an implicit temporal rela- excess all-cause mortality were found for dysthymic tionship between onset of ADHD (that is, several symp- disorder, consistent with previous findings (Baxter, Page, toms must be present prior to age 12) and dangerous and Whiteford 2011). driving, but also a plausible biological mechanism in As is the case for other disorders, YLL calculations the relationship, specifically, the characteristic pattern based on cause-of-death estimates for major depressive of inattention and impulsivity of ADHD that leads to disorder highlight the gap between those deaths that can dangerous driving. be causally attributed to a disorder and excess deaths, some of which will not be directly attributable to the Substance Use Disorders disorder. More than two million excess deaths produced Figure 3.6 shows the estimated number of cause-specific by DisMod-MR in 2010 is high, and likely to be an over- and excess deaths for each substance use disorder, estimate of directly attributable deaths when considered with estimated excess mortality by age and uncertainty in a strict cause-and-effect framework, but this finding bounds. highlights the importance of deciphering the complex interplay of factors linking major depressive disorder Alcohol Use Disorders. The number of cause-specific with other health outcomes. deaths attributed to alcohol use disorders in 2010 (111,000) was substantially lower than the number of Anxiety Disorders. The information on excess mortal- excess deaths (1.95 million) calculated using natural ity in anxiety disorders is inconsistent. Some anxiety dis- history models. orders, especially severe presentations of post-traumatic Light to moderate alcohol consumption has been stress disorder, have been associated with increased associated with lower rates of some diseases, such as deaths caused by IHD, neoplasms, and intentional diabetes mellitus and coronary heart disease. However, and unintentional injuries (Ahmadi and others 2011; heavy consumption has been associated with increased Lawrence, Hancock, and Kisely 2013). There is insuf- rates of chronic diseases, including cancer; mental, neu- ficient information, however, to determine whether rological, and substance use disorders; cardiovascular premature mortality is significantly raised across the disease; and liver and pancreas diseases (Rehm, Baliunas, entire spectrum of anxiety disorders (Baxter and others and others 2010): 2014). In GBD 2010, no YLLs or excess mortality were associated with the natural history of disease applied to • Evidence suggests that alcohol may be a carcinogen in the broad category of anxiety disorders. humans, with particularly strong causal links estab- lished between alcoholic beverage consumption and Disruptive Behavioral Disorders. Disruptive behav- oral cavity, pharynx, larynx, esophagus, liver, colo- ioral disorders are associated with poor health out- rectal, and female breast cancers (Rehm, Baliunas, comes across the lifespan. Research shows that children and others 2010). with ADHD or CD are two to three times more likely • A consistent relationship has been found between to experience unintentional injuries requiring medical heavy alcohol consumption and epilepsy (Rehm, attention than children without behavioral disorders Baliunas, and others 2010). (Lee and others 2008; Rowe, Maughan, and Goodman • Alcohol has been implicated in the development of 2004). The most commonly reported injuries included depression and personality disorders, although the Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 49 Figure 3.6 Cause-Specific and Excess Deaths Attributed to Substance Use Disorders, by Age, with Uncertainty, 2010 a. Alcohol use disordersa b. Opioid dependence 0.6 0.25 0.5 0.20 Global deaths (millions) Global deaths (millions) 0.4 0.15 0.3 0.10 0.2 0.05 0.1 0 0 4 9 4 9 4 4 4 4 4 4 + 4 9 4 9 4 4 4 4 4 4 + 1– 5– –1 –1 –2 –3 –4 –5 –6 –7 75 1– 5– –1 –1 –2 –3 –4 –5 –6 –7 75 10 15 20 25 35 45 55 65 10 15 20 25 35 45 55 65 Age Age c. Amphetamine dependence d. Cocaine dependence 0.12 0.050 0.045 0.10 0.040 Global deaths (millions) Global deaths (millions) 0.08 0.035 0.030 0.06 0.025 0.020 0.04 0.015 0.010 0.02 0.005 0 0 4 9 4 9 4 4 4 4 4 4 + 4 9 4 9 4 4 4 4 4 4 + 1– 5– –1 –1 –2 –3 –4 –5 –6 –7 75 1– 5– –1 –1 –2 –3 –4 –5 –6 –7 75 10 15 20 25 35 45 55 65 10 15 20 25 35 45 55 65 Age Age Upper UI (excess deaths) Mean excess deaths Lower UI (excess deaths) Upper UI (CoD counts) Mean CoD counts Lower UI (CoD counts) Source: IHME 2013. Note: CoD = cause-specific deaths; UI = uncertainty interval. Cannabis is not shown, as there was no cause-specific or excess mortality. a. Cause-specific deaths for alcohol use include those from alcohol dependence and fetal alcohol syndrome; differentially, excess deaths represent those from dependence only. direction of causality and the effects of confounding and intentional injuries, with strong evidence for factors remain uncertain (Rao, Daley, and Hammen a dose-response relationship (Rehm, Baliunas, and 2000; Rohde and others 2001). others 2010). • The relationship between alcohol consumption and • The risk of death through injuries and self-harm is liver cirrhosis is well recognized, but alcohol use dis- elevated, accounting for approximately 30 million orders appear to be more strongly related to cirrhosis YLLs globally. mortality versus morbidity, as it negatively affects the course of existing liver disease (Rehm, Baliunas, and The elevated risks in those with alcohol use disorders others 2010). appear to be mediated by the quantity of alcohol con- • Heavy alcohol use is related to higher rates of infec- sumed and the drinking pattern (Rehm, Baliunas, and tious diseases, such as tuberculosis, and unintentional others 2010). 50 Mental, Neurological, and Substance Use Disorders Illicit Drug Use Disorders. Between 95,800 (in cocaine gap between cause-specific and excess deaths. This finding dependence) and 404,000 (in opioid dependence) excess may reflect the increasing recognition of neurological deaths occurred in dependent illicit drug users in 2010, disorders as the primary cause of death. compared with 78,000 deaths in which illicit drug use was identified as the explicit cause. The majority of these Epilepsy. Epilepsy was modeled as an envelope con- cause-specific deaths—43,000—are attributable to opioid dition in GBD 2010; idiopathic epilepsy and epilepsy dependence (Degenhardt, Whiteford, and others 2013). were secondary to a range of causes, including men- Excess and premature deaths in illicit drug users ingitis, neonatal tetanus, iodine deficiency, and a occur in several ways, including the acute toxic effects of variety of birth complications modeled as one disorder. illicit drug use that may lead to overdose, specifically, the Cause-of-death modeling estimated nearly 200,000 cause-specific deaths captured by the ICD coding system. deaths caused by epilepsy in 2010; natural history In addition, substantial numbers of deaths are likely to be models show approximately 300,000 excess deaths. caused by the more indirect effects of intoxication that The high number of deaths in young children is clear result in accidental injuries and violence, cardiovascular in figure 3.7. disease, liver disease, and a range of mental disorders. Mortality in people with epilepsy is generally two- to Suicide is an important outcome, particularly for opi- three-fold higher than mortality in the general commu- oid users, where an SMR of approximately 14 has been nity (Preux and Druet-Cabanac 2005; Trinka and others reported in two separate reviews (Chesney, Goodwin, 2013). The relative mortality in those with epilepsy in and Fazel 2014; Degenhardt and others 2011). The injec- LMICs is significantly higher than in HICs (Carpio tion of drugs carries a high risk of blood-borne bacterial and others 2005; Diop and others 2005), particularly and viral infections, notably, human immunodeficiency in poorer, rural populations (Carpio and others 2005). virus and acquired immune deficiency syndrome (HIV/ Mortality data from HICs show that most deaths are AIDS), hepatitis B, and hepatitis C (Mathers and others caused by underlying conditions, such as neoplasms, 2010; Nelson and others 2011). cerebrovascular diseases, and cardiac disease (Spencer 2014); a greater proportion of deaths in LMICs appears Neurological Disorders to be related to epilepsy (Carpio and others 2005; Cause-specific death estimates are more substantial for Diop and others 2005) or to accident or injury (Carpio neurological disorders (figure 3.7), resulting in a smaller and others 2005; Kamgno, Pion, and Boussinesq 2003; Figure 3.7 Numbers of Cause-Specific and Excess Deaths Attributed to Neurological Disorders, by Age, with Uncertainty, 2010 a. Epilepsy b. Dementia 0.07 1.8 1.6 0.06 1.4 Global deaths (millions) 0.05 Global deaths (millions) 1.2 0.04 1.0 0.03 0.8 0.6 0.02 0.4 0.01 0.2 0 0 + + 4 9 4 9 4 4 4 4 4 4 4 9 4 9 4 4 4 4 4 4 75 75 1– 5– –1 –1 –2 –3 –4 –5 –6 –7 1– 5– –1 –1 –2 –3 –4 –5 –6 –7 10 15 20 25 35 45 55 65 10 15 20 25 35 45 55 65 Age Age Upper UI (excess deaths) Mean excess deaths Lower UI (excess deaths) Upper UI (CoD counts) Mean CoD counts Lower UI (CoD counts) Source: IHME 2013. Note: CoD = cause-specific deaths; UI = uncertainty interval. Migraine is not shown, as there was no cause-specific or excess mortality. Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 51 Mu and others 2011). These differences could be due 2010); 55 percent of the deaths in the cohort were directly partly to methodological differences or to genuine dif- related to epilepsy, including sudden, unexplained death ferences caused by the etiology of the disease and envi- in 30 percent, definite or probable seizure in 15 percent, ronmental risk factors. and accidental drowning in 10 percent. The proportion of deaths attributable to epilepsy Another important risk factor for premature mortal- differs by region. In GBD 2010, Sub-Saharan Africa ity is comorbid mental illness. Most studies of mortality had the highest death rates caused by epilepsy (Murray risk in this population have been conducted in HICs, and others 2012). Importantly, studies have shown that and the extent of this risk factor in resource-limited a large proportion of these deaths—those attributable settings is largely unknown. In a Swedish retrospective to falls, drowning, burns, and status epilepticus—is study, 75 percent of epilepsy patients dying from an preventable (Diop and others 2005; Jette and Trevathan external cause had comorbid psychiatric illness, most 2014). In a large cohort of people with active convulsive commonly depression and substance abuse (Fazel and epilepsy in rural Kenya, 38 percent of epilepsy-related others 2013). In a population-based study in the United deaths were caused by status epilepticus. Mortality in Kingdom, mortality among epilepsy patients was asso- this cohort was more than six-fold greater than expected ciated with alcohol use and depression (Ridsdale and and associated with nonadherence to (or unavailability others 2011). In a meta-analysis of studies on suicide in of) anti-epileptic drugs, cognitive impairment, and age epilepsy patients, Pompili and others (2005) found that (Ngugi and others 2014). the incidence of suicide was significantly higher among Kamgno, Pion, and Boussinesq (2003) found simi- epilepsy patients than the general population. This strik- larly high mortality rates in Cameroon, associated with ing mortality risk in epilepsy patients with mental disor- poor access to or compliance with medical treatment. ders requires further study and intervention in LMICs, In a study of 164 patients with epilepsy followed for 30 where the burden of epilepsy is highest. years in Tanzania and treated with phenobarbital, 67.1 percent of the patients died, a mortality rate twice that Dementia. Our natural history model attributed more of the rural Tanzanian population. The causes of death than two million excess deaths worldwide to dementia were related to epilepsy in more than 50 percent of the in 2010, compared with 500,000 cause-specific deaths patients and included status epilepticus, drowning, and derived from ICD records. Figure 3.7 shows that the burns (Jilek-Aall and Rwiza 1992). majority of deaths caused by dementia, as expected, In other LMICs outside Sub-Saharan Africa, the pre- occur in the elderly. ventable causes of death in epilepsy patients are also a Excess mortality in dementia has been associated significant factor. Drowning is the most common cause with functional disability leading to unhealthy lifestyle of premature death in rural China (proportional mor- factors and comorbid physical conditions (Guehne, tality ratio = 82.4 percent). This finding is attributed in Riedel-Heller, and Angermeyer 2005; Llibre and others part to geographic and occupational risk hazards that 2008). Midlife cardiovascular risk factors have been include living and working around ponds, paddy fields, associated with later mortality in patients who develop cesspits, and wells (Mu and others 2011). dementia. In a Norwegian prospective study following Epilepsy is associated with premature mortality, with patients for 35 years, dementia mortality was associated the highest SMR in the first one to two years following with increased total cholesterol levels, diabetes mellitus, diagnosis (Neligan and others 2010). Common causes and low body mass index in midlife (Strand and others of premature mortality in epilepsy include acute symp- 2013). A study in seven countries found that smoking, tomatic disorders, such as brain tumor or stroke; sudden hypercholesterolemia, high blood pressure, low forced unexpected death in epilepsy; suicides; and accidents vital capacity, and previous history of cardiovascular (Hitiris and others 2007). The epidemiology of premature disease at baseline were associated with a higher risk of mortality is very relevant in LMICs, where 85 percent of death from dementia (Alonso and others 2009). those with epilepsy live and where the risk of premature Dementia shows an increased mortality risk. In a mortality is highest (Diop and others 2005; Jette and study of male civil servants who participated in the Trevathan 2014; Newton and Garcia 2012). Particularly Israel Heart Disease study, patients with dementia had concerning is the risk of premature mortality in childhood a hazard ratio for mortality of 2.27 compared with onset epilepsy. In a prospective trial in Finland of patients patients without dementia (95% CI, 1.92–2.68) (Beeri with childhood onset epilepsy followed for 40 years, and Goldbourt 2001). 24 percent of the patients died. This rate is three times The severity of disease is one of the most signifi- higher than the expected age- and gender-adjusted mor- cant predictors of premature death in individuals with tality in the general population (Sillanpää and Shinnar dementia after controlling for other factors, with an HR 52 Mental, Neurological, and Substance Use Disorders for moderate cases of 2.0 (95% CI, 0.1-4.1) compared age-grouping at this age (table 3.2). If dementia deaths with mild cases, and an HR of 3.8 (95% CI, 2.7-3.4) for are excluded, the number of deaths attributable to severe cases compared with mild cases (Gühne and oth- mental, neurological, and substance use disorders is ers 2006). In a cohort of 15,209 patients in the Swedish highest between ages 35 and 54 years; most are caused Dementia Registry, lower scores on the mini-mental by epilepsy and alcohol use disorders. status examination, male gender, higher number of Table 3.2 shows that the cause-specific deaths and medications, institutionalization, and age were associ- excess deaths directly coded to mental, neurological, ated with increased death risk after dementia diagnosis and substance use disorders are relatively similar up to (Garcia-Ptacek and others 2014). age four years. After this age point, excess deaths rise Infections, particularly pneumonia, frequently lead sharply in relation to cause-specific deaths. As with to death in people with dementia (Mitchell and others cause-specific deaths, the greatest number of excess 2009). Urinary tract infections caused by incontinence, deaths occurs at ages 75 years and older due to dementia. as well as bedsores and deep venous clots caused by If dementia deaths are excluded, excess deaths would immobility, can lead to systemic bloodstream infections peak between 25 and 54 years of age; the majority is and death. Psychological agitation and aggression are attributable to alcohol use disorders. frequent symptoms in patients with dementia, and antipsychotics are frequently prescribed, although sig- nificant increased mortality risk odds ratio (OR 1.7) is Counter-Factual Burden and Comparative Risk associated with typical and atypical antipsychotics. This Assessment practice has resulted in a formal black box warning by In GBD 2010, literature investigating mental, neurologi- the United States Food and Drug Administration (U.S. cal, and substance use disorders as risk factors for other FDA 2008). An independent, systematic review of 15 health outcomes was reviewed. Because of data limita- randomized control trials (RCTs) of atypical antipsy- tions, only a few risk factor–outcome pairings could chotics confirmed the significant increased risk (OR be established and assessed in the study’s CRA analysis 1.54) for all antipsychotics (Schneider, Dagerman, and (Baxter and others 2011; Lim and others 2012). These Insel 2005). The dementia antipsychotic withdrawal risk factors are summarized in table 3.3. There were trial (DART-AD) trial reported increased mortality in insufficient data to assess neurological disorders as risk patients who were prescribed agents in the long term factors in GBD 2010. From the data that were available and likely related to oversedation, dehydration, and for selected mental and substance use disorders, we can prolongation of QT interval corrected for heart rate on begin to appreciate the impact these disorders have on electrocardiogram (Ballard and others 2009). other health outcomes in the GBD cause list. A clear causal relationship exists between dementia Online annex 3A summarizes the YLLs allocated to and premature death; however, other environmental mental, neurological, and substance use disorders as factors can precede both outcomes and independently direct causes of death; these were estimated using previ- increase the risk of dementia and excess mortality. For ously reported cause-specific death estimates. In addi- example, education and literacy may confer a degree tion to these cause-specific YLLs, mental and substance of protection against dementia and excess mortality use disorders are responsible for 22.5 million YLLs (Prince and others 2012). Thus, these factors, which are caused by deaths from suicide; major depression is already high on the agenda for LMICs, may be consid- responsible for 3.5 million YLLs caused by deaths from ered independent, modifiable risk factors in reduced life IHD; injecting drug use is responsible for 7.2 million expectancy, explaining a portion of the excess mortality YLLs caused by deaths from blood-borne viruses and currently associated with dementia. liver disease; and alcohol use is responsible for 78.7 mil- lion YLLs from death caused by various additional outcomes. Regular cannabis use as a risk factor for Deaths across the Lifespan schizophrenia accounted for an estimated 7,000 DALYs Cause-specific deaths from mental, neurological, and globally, all of which were YLDs given that there was substance use disorders increase steadily across the no evidence to suggest an elevated risk of mortality in lifespan, with the exception of a peak at ages one to cannabis users (Charlson and others 2013; Degenhardt, four years caused by epilepsy-related deaths. The great- Ferrari, and others 2013; Ferrari and others 2014; Lim est number of deaths occurs in the oldest group (ages and others 2012). 75 years and older). This finding is explained almost Figure 3.8 shows the additional YLLs attributable to entirely by dementia, including Alzheimer’s disease, mental, neurological, and substance use disorders as risk although it may, at least in part, be caused by the broad factors for other health outcomes by region; these are Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 53 54 Table 3.2 Number of Cause-Specific and Excess Deaths, by Age, 2010 0–1 1–4 5–9 10–14 15–19 20–24 25–34 35–44 45–54 55–64 65–74 75+ Cause-specific deaths years years years years years years years years years years years years Total Alzheimer’s disease and other dementias - - 869 605 578 642 1,259 2,302 4,575 12,559 41,622 420,710 485,721 Epilepsy 7,388 19,819 6,255 5,351 10,562 14,101 24,107 20,605 18,038 14,826 14,522 22,054 177,627 Schizophrenia - - - - - - 2,003 3,610 3,429 3,440 3,035 4,246 19,763 Mental, Neurological, and Substance Use Disorders Alcohol use disorders - - - - 464 1,311 7,937 20,044 33,613 27,446 13,295 7,024 111,134 Opioid dependence 1,231 1,217 288 260 1,350 3,745 9,736 8,446 7,432 3,846 2,319 3,171 43,040 Cocaine dependence 13 12 3 3 16 47 120 107 96 53 33 44 549 Amphetamine dependence 13 11 3 3 14 40 102 88 75 44 30 41 465 0–1 1–4 5–9 10–14 15–19 20–24 25–34 35–44 45–54 55–64 65–74 75 + Excess deaths years years years years years years years years years years years years Total Alzheimer’s disease and other dementias - - - - - - - 1,160 114,334 267,613 251,719 1,478,957 2,113,783 Epilepsy 3,513 13,486 10,680 9,050 18,957 25,784 54,590 52,928 38,961 25,330 20,276 22,647 296,201 Schizophrenia - - - 816 8,758 26,990 106,121 163,634 208,056 118,828 43,846 21,945 698,993 Alcohol use disorders - - - 6,868 46,164 85,768 403,572 510,864 472,712 304,907 91,601 31,046 1,953,502 Opioid dependence - - - - 11,268 94,748 183,102 77,352 28,489 7,350 1,498 319 404,125 Cocaine dependence - - - - 638 10,334 38,838 23,083 16,682 5,023 984 237 95,818 Amphetamine dependence - - - - 5,856 25,306 86,702 65,420 17,058 1,765 101 11 202,219 Major depressive disorder - 239 63,015 86,160 141,417 171,916 284,968 286,056 285,313 258,639 198,975 447,142 2,223,840 Bipolar disorder - - - 1,337 21,063 78,773 327,425 401,817 266,179 136,888 58,706 28,204 1,320,391 Autistic disorder 963 4,220 3,883 3,087 3,918 5,102 13,468 18,276 20,536 17,133 10,675 7,384 108,645 Source: Lozano and others 2012. Note: Larger than expected numbers in the 75+ age group may be an artefact of the age groupings. - = nil. Table 3.3 Mental, Neurological, and Substance Use Disorders Included as Risk Factors in the GBD 2010 Comparative Risk Assessments and Attributable YLLs for Health Outcomes, 2010 Millions of YLLs Risk Outcome (95% uncertainty) Alcohol use Alcohol use disorders, tuberculosis, lower respiratory infections, multiple cancers, 78.7 cardiovascular and circulatory diseases, cirrhosis of the liver, pancreatitis, epilepsy, (70.9–86.8) diabetes mellitus, injuries, and interpersonal violence Injecting drug use HIV/AIDS, hepatitis B and C, liver cancer, and cirrhosis of the liver secondary to hepatitis 7.2 (5.6–9.7) Mental and substance Suicide 22.5 use disorders (14.8–29.8) Major depression Ischemic heart disease 3.6 (1.8–5.4) Regular cannabis usea Schizophrenia 0 Sources: Estimates based on Charlson and others 2013; Degenhardt, Ferrari, and others 2013; Ferrari and others 2014; Lim and others 2012. Note: DALYs = disability-adjusted life years; HIV/AIDS = human immunodeficiency virus and acquired immune deficiency syndrome; YLD = years lived with disability; YLL = years of life lost. a. Regular cannabis use as a risk factor for schizophrenia accounted for an estimated 7,000 DALYs globally, all of which were YLDs. over and above cause-specific YLLs directly attributable Figure 3.8 Absolute YLLs Attributable to Mental, Neurological, to these disorders. Variation in absolute YLLs among and Substance Use Disorders as Risk Factors for Other Health regions is explained not only by population size, but Outcomes, 2010 also the distribution of the risk factors and outcomes 100 in each region. For example, YLLs attributable to alco- hol use as a risk factor are greatest in Central Europe, Eastern Europe, and Central Asia—rather than South 80 Absolute YLLs (millions) Asia, which has the largest population size—because of high rates of alcohol use disorders in this region. In 60 contrast, the lower contribution of attributable YLLs in Sub-Saharan Africa likely reflects the lower rates of alco- hol use disorders in this region. Had there been sufficient 40 data to estimate YLLs caused by neurological disorders as risk factors for other health outcomes, estimates of 20 attributable YLLs may have been higher in Sub-Saharan Africa, where cause-specific deaths from neurological disorders are highest. 0 MSDs - Suicide Alcohol use - IDU - Multiple Major The attributable YLLs presented provide more com- Multiple outcomes outcomes depression - IHD prehensive insight into the magnitude of the burden Risk factor of mental, neurological, and substance use disorders. Sub-Saharan Africa South Asia For example, the addition of attributable suicide YLLs North Africa and Middle East Latin America and Caribbean would have changed total YLLs caused by mental and High-income Central Europe, Eastern Europe, substance use disorders combined from 0.5 percent and Central Asia Southeast Asia, East Asia, and Oceania (allocated to them as a direct cause) to 1.8 percent of global YLLs, elevating them from the fifth to the third Source: IHME 2013. leading disease category of global burden (DALYs) in Note: Risk factor–outcome pairings are defined in table 3.3. IDU = injecting drug use; IHD = ischemic heart disease; MSDs = mental and substance use disorders; YLLs = years of life lost to premature 2010 (Charlson and others 2013; Degenhardt, Ferrari, mortality. and others 2013; Ferrari and others 2014; Lim and others 2012). Attributable YLLs estimated for each risk factor– outcome pairing are not mutually exclusive of contri- butions of other risk factors; consequently, they cannot be aggregated to estimate the overall YLLs attributable Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 55 to all mental, neurological, and substance use disorders severe and persistent mental disorders may be less combined. Nevertheless, presenting attributable YLLs likely to receive a timely diagnosis of physical illness is another example of the deaths and YLLs caused by because of diagnostic overshadowing, that is, physical these disorders, over and above the direct cause-specific complaints may be overlooked and attributed to psy- deaths and YLLs allocated to each disorder in GBD chological and psychiatric factors (Bailey, Thorpe, and 2010. It is clear that the mortality-associated disease is Smith 2013). A review by Happell, Scott, and Platania- significant. Phung (2012) found a reduced likelihood for people with mental disorders to receive screening for breast, cervical, and colorectal cancer or immunizations for DISCUSSION AND IMPLICATIONS influenza and pneumonia, compared with the rest of the population. Even in countries with well-established Mental Disorders health care systems, people with mental disorders The GBD findings of elevated rates of excess mortality receive lower-than-average prescriptions for medica- across most mental and substance use disorders are sup- tion treating cardiovascular disease (Kisely, Campbell, ported by the findings of a recent meta-analytic review and Wang 2009; Mitchell and Lord 2010) and are (Walker, McGee, and Druss 2015). Moreover, recent less likely to receive coronary artery bypass grafting, studies suggest that the majority of excess deaths are cardiac catheterization, or cerebrovascular arteriogra- caused by preventable diseases, with a smaller propor- phy (Kisely, Campbell, and Wang 2009; Mitchell and tion attributed to unnatural or unknown causes (Fekadu Lawrence 2011). and others 2015; Lawrence, Hancock, and Kisely 2013). Strategies for reducing mortality associated with The question remains as to what proportion of these mental and substance use disorders primarily target pre- deaths can be directly attributed to mental disorders and venting onset, reducing case fatality, and preventing the how much to subsequent confounding factors. development of fatal sequela. Growing evidence indi- Despite the existence of complex relationships cates that excess mortality in people with these disorders between mental disorders and premature mortality, can be reduced through established evidence-based some relationships, such as that between mental dis- treatments and improved screening and treatment for orders and suicide, are well-established (Li and others chronic disease. 2011). Mental disorders have also been linked to higher Psychiatric treatments, specifically pharmacother- rates of death caused by cardiovascular disease, stroke, apies, may have some protective effect against excess diabetes mellitus, respiratory diseases, and some cancers mortality (Weinmann, Read, and Aderhold 2009), (Crump and others 2013; Hoyer, Mortensen, and Olesen although evidence suggests that this depends on the 2000). The relationship between mental disorders and use of medications according to best practice guidelines a specific physical disease, leading to premature death, (Cullen and others 2013). However, some antidepres- is also complex. People with major depression are more sants and second-generation antipsychotics may actually likely to develop cardiovascular disease (Charlson and pose an elevated risk mediated by metabolic side effects others 2011). Psychotropic medications can negatively (Newcomer 2005; Rummel-Kluge and others 2010; impact cardiovascular and metabolic health (De Hert Smith and others 2008). and others 2012). Obesity and metabolic disturbances Collaborative care by community-based health teams are primary risk factors for cardiovascular disease and has the potential to reduce overall mortality, as well type II diabetes, and these are two- to three-fold more as suicide deaths (Dieterich and others 2010; Malone common in people with mental disorders, compared and others 2007). The use of collaborative care mod- with the general population (Scott and Happell 2011). els to improve physical health in people with mental, Major modifiable risk factors for chronic disease, such neurological, and substance use disorders is growing as smoking (Lawrence, Mitrou, and Zubrick 2009), poor in HICs; these models have demonstrated a range of diet, physical inactivity (Kilbourne and others 2007; positive health outcomes, including reduced cardiovas- Shatenstein, Kergoat, and Reid 2007), and substance cular risk profiles (Druss and others 2010). The effec- abuse (Scott and Happell 2011), are overrepresented in tiveness of these strategies in preventing premature people with mental disorders. These risk factors may be mortality in LMICs has yet to be tested, but this may be a the consequences of symptoms of mental, neurological, cost-effective approach to treatment in settings in which and substance use disorders; medication effects; and trained mental health clinicians are scarce. poor emotional regulation (Scott and others 2013). Known chronic disease risk factors, such as smok- Mental disorders are associated with poorer clinical ing and obesity, are potentially modifiable. Lifestyle management of comorbid conditions. People with interventions comprising a psycho-educational or 56 Mental, Neurological, and Substance Use Disorders behavioral approach can achieve modest but signifi- this burden could be averted by scaling up needle and cant improvements, such as reduced smoking (Kisely syringe programs, opioid substitution treatment (OST), and Campbell 2008; van Hasselt and others 2013), and HIV antiretroviral therapy (Degenhardt and others increased physical activity, and improved eating hab- 2010; Turner and others 2011). Increasing evidence indi- its (Verhaeghe and others 2011), resulting in reduced cates that needle and syringe programs can reduce the body mass index and improved metabolic profiles burden of HIV/AIDS (Degenhardt and others 2010) and (Gierisch and others 2013). hepatitis C virus (HCV) (Turner and others 2011). The Screening, prevention of metabolic risk factors, and HCV burden can also be decreased by effectively treat- proactive provision of basic health care services are ing chronic HCV (Turner and others 2011). The release essential to improve life expectancy in people with of more effective and less toxic HCV drugs is expected comorbid mental and physical health issues. Strategies to result in dramatic improvement in what have been for early cancer detection need to be prioritized, and extremely low rates of treatment uptake by people who models of care need to be developed to ensure that peo- inject drugs (Swan 2011). ple with these disorders receive the same level of physical More effective strategies to reduce the burden of dis- health care and treatment as the rest of the population. ease attributable to opioid dependence include mainte- Several guidelines address the management of men- nance OST and HIV antiretroviral therapy (Degenhardt tal, neurological, and substance use disorders. The World and others 2010; Turner and others 2011). The two Health Organization (WHO), for example, has devel- most commonly used medications, methadone and oped specific strategies in its Mental Health Gap Action buprenorphine, are on the List of Essential Medicines Programme, which aim to scale up services in LMICs (WHO 2005) as core medications for the treatment of (http://www.who.int/mental_health/mhgap/en/). The opioid dependence (Mattick and others 2008, 2009). WHO has also developed guidelines for other related OST reduces mortality among opioid dependent peo- health priorities, such as suicide, which draws atten- ple (Brugal and others 2005; Caplehorn and Drummer tion to the pivotal role that mental health care plays in 1999; Darke, Degenhardt, and Mattick 2006; Davoli suicide prevention (http://www.who.int/mental_health and others 1994; Degenhardt, Randall, and others 2009; /prevention/suicide/suicideprevent/en/index.html). Gibson and others 2008), with time spent in treatment Strategies to address self-harm remain critical, as halving mortality compared with that of time spent not evidence shows that a proportion of suicide deaths can in treatment (Degenhardt and others 2011). A large eval- be averted through public health measures. Policies that uation study in multiple countries, including LMICs, address restriction of access to common methods of sui- demonstrated that OST is effective in reducing opioid cide are effective in reducing suicide risk (WHO 2012). use and injecting risk behaviors and improving physical Strong evidence indicates that improved prevention and and mental well-being (Lawrinson and others 2008). treatment of major depression and alcohol and sub- There is scope for reducing the risk of overdose stance abuse can reduce suicide rates. among people who continue to use opioids, particularly The continuing life expectancy gap in persons with in countries with high injecting drug use rates but a mental disorders is a clear example of discrimination low emphasis on harm reduction measures, such as the and lack of parity between this portion of the pop- Russian Federation and the United States. Increasing ulation and the community in general (Thornicroft evidence indicates that the provision of the opioid 2013). Differential access to usual care for this group antagonist naloxone to users enables peers to intervene leads to poorer outcomes in terms of health loss and effectively if overdoses occur (Galea and others 2006; mortality (Liao and others 2013) and incurs high costs Sporer and Kral 2007). Additional strategies may include in health care provision (Centre for Mental Health educating users about the risks of overdose and conduct- 2010). Accordingly, identification of physical health ing motivational interviews with users who have recently issues and equitable access to health care are essential to overdosed (Sporer 2003). Safe injecting rooms have been improve long-term health outcomes and reduce excess proposed as an additional strategy to reduce overdose, mortality among people with mental disorders (Bass although their population reach is likely to be more and others 2012). limited (Hall and Kimber 2005). Psychosocial interventions, including self-help programs and cognitive behavioral therapy, can be Substance Use Disorders effective (Baker, Lee, and Jenner 2005; Knapp and Opioid dependence and injecting drug use are sig- others 2007). There is no evidence to date that phar- nificant contributors to the global burden of mental, macotherapies, such as mood stabilizers, antidepres- neurological, and substance use disorders. Much of sants, or antipsychotics, are effective for the treatment Excess Mortality from Mental, Neurological, and Substance Use Disorders in the Global Burden of Disease Study 2010 57 of stimulant dependence (Srisurapanont, Jarusuraisin, many LMICs and upper-middle-income countries (Jette and Kittirattanapaiboon 2001). The RCTs of prescribed and Trevathan 2014). Legislation to ensure the avail- psychostimulants in cocaine dependence have not found ability of affordable and efficacious anti-seizure medi- that they lead to greater abstinence or retention in care cations, clinician education in prescribing anti-epileptic (Castells and others 2010). medications, and patient education on the importance In some regions, notably Asia, there is also wide- of medical adherence is critical to alleviate the epilepsy spread delivery of non-evidence-based responses to treatment gap. Cost-effective epilepsy treatments are psychostimulant dependence (Degenhardt and others available, and accurate diagnosis can be made without 2010, 2014). Illicit drug users may be detained in costly technical equipment. Targeting epilepsy risk fac- closed settings, typically operated by military, gov- tors, including more common structural and metabolic ernment security, or police for what is claimed to be causes of epilepsy, can decrease mortality risk. Education treatment, most often for psychostimulant use (IHRD and information on safe lifestyle habits in epilepsy 2009; Pearson 2009; UNODC Regional Centre for patients will benefit populations in LMICs, as will edu- East Asia and the Pacific 2006; WHO 2009). Detainees cation initiatives targeted to employers and teachers to are often forced to comply with the interventions; dispel the myths associated with epilepsy. evidence-based, effective drug treatment and HIV The mortality risk of dementia in many LMICs is prevention are rarely delivered (General Department poorly known. Studies on the mortality rates due to for Social Evils Prevention, Constella Group, and dementia and the incidence of preventable risk factors in DFID 2008; IHRD 2009; UNODC Regional Centre for these regions are critical to develop strategies to alleviate East Asia and the Pacific 2006; WHO 2009). External mortality in this fragile patient population. Mortality in evaluations have concluded that there may be adverse dementia patients is commonly caused by preventable impacts on drug use and HIV risk (Pearson 2009), in medical conditions. Caregiver education and support addition to human rights violations (Human Rights services regarding proper care of patients with cognitive Watch 2004; IHRD 2009; Pearson 2009; Rehm, Csete, decline will likely decrease infection rates and mortality. and others 2010; WHO 2009). Government financial support for health care services Although cannabis dependence had no YLLs, two and caregiver support would benefit this population. million YLDs were attributed to the disorder. Behavioral Strategies to enhance nutrition, as well as monitoring interventions are effective in the treatment of cannabis and treatment of vascular risk factors, are important dependence (Denis and others 2013; Knapp and others measures. Raising awareness of the mortality risk among 2007); cognitive behavioral therapy and contingency the public, caregivers, and health workers can lead to management show the greatest promise. Public health increased demand for services. campaigns may be necessary to advise young people of the risks of developing dependence on cannabis, because many users fail to appreciate this risk. More research is needed, however, into how to scale up these behavioral CONCLUSIONS AND LIMITATIONS approaches to reduce the population prevalence of these Quantifying mortality presents several challenges. disorders (Knapp and others 2007). The cause-of-death data are affected by multiple fac- tors, including certification skills among physicians, diagnostic and other data available for completing Neurological Disorders the death certificate, cultural variations in choosing As the incidence of neurological disorders, including and prioritizing the cause of death, and institutional epilepsy and dementia, grows in many resource-limited parameters governing mortality reporting (Lozano and settings, strategies to decrease mortality rates in these others 2012). In LMICs, where many deaths are not regions in particular must be addressed. Improvements medically certified, different data sources and diagnos- in access to medical treatment, patient and clinician tic approaches are used to derive cause-of-death esti- education, and a focus on preventable causes of death mates (Lozano and others 2012). Overall, improving can substantially decrease mortality rates. and expanding sources of national mortality estimates In resource-constrained settings, the mortality risk is imperative. in epilepsy patients is up to six times higher than in Mortality directly related to mental, neurological, and HICs and largely due to preventable causes (Kamgno, substance use disorders is particularly difficult to cap- Pion, and Boussinesq 2003; Ngugi and others 2014). ture in cause-of-death data because of the complex web The epilepsy treatment gap is more than 75 percent in of causality that links these disorders with other physical low-income countries, and more than 50 percent in disorders. It is important to identify and quantify the 58 Mental, Neurological, and Substance Use Disorders excess premature mortality in people with these disor- World Bank Income Classifications as of July 2014 are as fol- ders by elucidating the pathway between the disorders lows, based on estimates of gross national income (GNI) per and fatal sequelae. The estimates of excess mortality capita for 2013: presented in this chapter include deaths from causal and noncausal origins and therefore cannot be interpreted as • Low-income countries (LICs) = US$1,045 or less • Middle-income countries (MICs) are subdivided: the number of deaths directly attributable to a particular a) lower-middle-income = US$1,046 to US$4,125 disorder. In addition, DisMod-MR natural history mod- b) upper-middle-income (UMICs) = US$4,126 to US$12,745 els do not adjust for co-occurrence between disorders. • High-income countries (HICs) = US$12,746 or more. 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Collins, and Vikram Patel INTRODUCTION 8 million deaths annually due to medical conditions are attributable to mental disorders (Walker, McGee, and Burden of Disease Druss 2015). Mental disorders are a diverse group of conditions that Mental disorders are associated with social stigma in primarily impair cognition, emotion, and behavioral many countries and cultures (Weiss and others 2001). control; occur early in life; and have a high aggregate The slow emergence of scientific explanations for the eti- prevalence in all countries where epidemiology has been ologies of mental disorders and the mistaken belief that investigated (Demyttenaere and others 2004; Kessler, symptoms reflect either a lack of will power or some moral Berglund, and others 2005; WHO 1992). The combina- failure facilitate negative attitudes and discrimination. tion of high prevalence, early onset, clinical course that Patients with psychotic symptoms can seem frightening, is either chronic or remitting and relapsing, and impair- but persons with mental illnesses are far more likely ment of critical brain functions makes mental disor- to commit suicide than homicide and to be victims of ders a major contributor to the global disease burden crimes than perpetrators (The Lancet 2013; Walsh and discussed in chapter 2 in this volume (Whiteford and others 2003). Shame and fear are substantial obstacles others 2015). The greatest fraction of the burden results to help-seeking, diagnosis, and treatment. Individuals from years lived with disability (YLDs), particularly for with mental disorders are often imprisoned, without ages 15–49 years—a critical life interval for completing access to adequate care, for minor legal transgressions education, starting a family, and increasing productivity that result directly from their illnesses. In many mental at work (figure 4.1) (WHO 2014b). The global cost hospitals and other settings, people with these disorders of mental health conditions is projected to be as high may not be accorded basic human rights. Stigmatization as US$6 trillion by 2030, of which 35 percent would has contributed to disparities in availability and access to be contributed by low- and middle-income countries care and medications and insurance coverage, as well as (LMICs) (Bloom and others 2011). research funding, compared with other chronic illnesses Although mental disorders directly account for fewer (Wang, Aguilar-Gaxiola, and others 2007). than half of one percent of all deaths, they contribute This chapter updates data on the disease burden, as significantly to premature mortality through multi- well as interventions to treat the four leading contrib- ple medical causes (discussed in chapter 3 in this utors to adult mental illness globally—schizophrenia, volume, Charlson and others 2015) and are a major bipolar disorder, depressive disorders, and anxiety risk factor for suicide (WHO 2014c; chapter 9 in this disorders. These were selected because of their high volume, Vijayakumar and others 2015). An estimated contribution to the global disease burden, accounting Corresponding author: Steven Hyman, Stanley Center for Psychiatric Research, Broad Institute of the Massachusetts Institute of Technology and Harvard University; and Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, Massachusetts, United States of America, seh@harvard.edu. 67 Figure 4.1 Years Lived with Disability Caused by Unipolar Depression, Among the disorders discussed in this chapter, Anxiety Disorders, Bipolar Disorder, and Schizophrenia Globally schizophrenia and bipolar disorder are the most highly influenced by genes, with estimated heritabilities of 65 60 to 80 percent (Sullivan, Daly, and O’Donovan 2012). Genotyping of nearly 40,000 individuals with schizo- 50 phrenia and a larger number of healthy comparison subjects has revealed 108 genomewide significant loci that contribute to risk, with different combinations of 40 risk alleles acting in different individuals (Ripke and oth- YLDs in millions ers 2014). Genes exert less influence, and environmental 30 risk factors more, in depressive and anxiety disorders (Sullivan, Daly, and O’Donovan 2012). 20 The relative risk of developing psychopathology involves interactions with genetic and developmental risk factors (Digangi and others 2013). Adverse cir- 10 cumstances in childhood have been associated with risk; histories of early childhood abuse, violence, 0 poverty, and experiences of significant loss correlate with risk of multiple mood and anxiety disorders rs hs s rs rs rs rs ys ar ea ea ea ea ea nt da ye 9y mo +y 9y 9y (Heim and others 2010; Patel and Kleinman 2003). 9y 27 14 –4 70 –5 –2 –6 59 0– 5– 30 50 15 60 Through complex pathways, people with chronic 1– physical illnesses like diabetes, chronic obstructive Age groups pulmonary disease, cardiovascular disease, arthritis, YLDs (female) YLDs (male) and cancer have a greater likelihood of developing mental disorders, particularly depression (Moussavi Source: WHO 2014b. Note: YLDs = years lived with disability. and others 2007). Similarly, individuals who have sustained traumatic brain injuries have a greater likeli- hood of developing mental disorders (Jorge and others for 66 percent of disability-adjusted life years (DALYs) 2004). Environmental triggers are best documented lost and 69 percent of YLDs due to mental and behav- in post-traumatic stress disorder (PTSD), but even ioral disorders, as well as based on the availability of here individuals vary enormously in the threshold data for cost-effectiveness analyses. We begin with a brief of stress severity associated with PTSD. Replicated summary of the etiology of these disorders, followed environmental risk factors for schizophrenia include by a more detailed description of the burden and epi- urban birth, migrant status, season of birth, and demiology of each group of disorders and the evidence possibly viral infections during pregnancy (Sorensen on treatment. Throughout this chapter, although we and others 2014). These environmental risk factors attempt to emphasize data from LMICs, most of the data are proxies for causal mechanisms that remain to be are from high-income countries (HICs). identified and that interact with genetic risk factors to produce illness (McGrath and Scott 2006). Gender is associated with the risk of many mental Risk Factors disorders; men have higher rates of schizophrenia, and The etiologies of mental disorders involve interactions women have higher rates of depressive and anxiety among genetic, developmental, social, and environmen- disorders (Patel and others 2006). The reasons for these tal risk factors. Mental disorders are polygenic, mean- differences are likely related to genetic and social factors ing that hundreds of risk variants in DNA sequence that may expose a particular gender to a higher burden exist across global populations, much like type 2 dia- of risk factors. Bipolar disorder affects men and women betes mellitus and hypertension. An individual’s risk equally. results from the aggregation of some disease-associated alleles (alternative forms of a gene at a given locus) in combination with environmental factors. Strong evi- dence suggests that multiple psychiatric disorders share MOOD AND ANXIETY DISORDERS a significant fraction of genetic risk factors (Lee and Mood disorders differ from normal variation others 2013). in emotional state by their persistence across time 68 Mental, Neurological, and Substance Use Disorders and situations—each episode lasting weeks or even concentrating, slow thinking, ruminations, and poor months—and accompanying physiological and memory. Some individuals with depression exhibit cognitive symptoms. Mood disorders are divided into slowed motor movements (psychomotor retardation), unipolar depressive disorders and bipolar disorder, in while others may be agitated. Psychotic symptoms occur which manic episodes also occur. The unipolar-bipolar in a minority of cases, most often congruent with the distinction is well supported by studies of families, depressed mood. Thus, a person might hear relentlessly genetics, and treatment response. critical voices. During an episode of a mood disorder, a person may be predominantly sad or emotionally withdrawn Epidemiology and Burden of Disease (depressive disorders), elated (mania), or irritable Depression is an episodic disorder that generally begins (mania or depression). The emotions are relatively early in life (median age of onset is in the mid- to late inflexible; for example, a person with a depressive disor- 20s), although new onsets can be observed across the der cannot respond appropriately to happy or rewarding lifespan. Childhood onset is being increasingly recog- stimuli. The physiological disturbances typical of mood nized, although not all childhood precursors of adult disorders include abnormalities in sleep, appetite, libido, depression take the form of a clearly diagnosable depres- and energy. Cognitive abnormalities associated with sive disorder. A pattern of remissions and relapses is mood disorders include impairment in attention and typical, with recurrence risk greater among those with memory, as well as mood-dependent changes in the early-onset disease (Lewinsohn and others 2000). Many content of thought. individuals do not recover fully from acute episodes and Severe depression and mania may be characterized suffer a persistent depressive disorder that exerts neg- by psychotic symptoms. Due to frequent occurrence ative effects on public health worldwide (Gureje 2011) of psychotic symptoms during the manic phase of and is a risk factor for suicide. bipolar disorder, it can also be considered a type Depression is often comorbid with other mental of psychotic disorder. In many LMICs, concurrent disorders (Kessler, Chiu, and others 2005); roughly half somatic symptoms are commonly reported with mood of the people who have a history of depression also have and anxiety disorders and may be the chief complaint. an anxiety disorder in their lifetime. Depression is fre- For example, patients suffering from depression might quently comorbid with obesity and general medical dis- not complain of emotional symptoms but of fatigue orders, such as type 2 diabetes mellitus, coronary artery or multiple aches and pains. Many reasons have been disease, and chronic pain disorders. suggested for this phenomenon, including the stigma The 12-month prevalence of depressive disorder, associated with mental disorders and patients’ expec- dysthymia, or bipolar disorder among the 17 countries tation that physical symptoms have more salience in that participated in the World Health Organization’s medical consultations. (WHO) World Mental Health (WMH) surveys ranged between 1.1 percent in Nigeria and 9.7 percent in the United States, with an interquartile range (IQR)—which Depressive Disorder covers the 25th to 75th percentiles—of 3.4 to 6.8 percent Clinical Features and Course and substantial cross-country variations (Kessler and Clinically significant depression is distinguished from others 2008).1 These wide differences in prevalence may normal sadness or grief by its severity, persistence represent both methodological differences (notably dif- across time and situations, duration, and associated ficulties in self-reporting conditions that are stigmatized physiological and behavioral symptoms. The cardinal across cultures) and true differences due to the interplay symptoms include a period of persistent sadness or among the genetic, developmental, and environmental other negative affective states, such as loss of interest in factors that might differ across countries. previously pleasurable pursuits, or anhedonia (inabil- Depression also leads to substantial impairments in ity to experience pleasure). Physiological symptoms productive and social roles (Wang, Simon, and Kessler occur across cultures, including sleep disturbance, 2003) and is the single largest contributor to the non- most often insomnia (with early morning awakening), fatal burden globally (WHO 2014b). Depression is a but occasionally excessive sleeping; appetite distur- leading risk factor for suicide—a risk that is exacerbated bance (usually loss of appetite and weight loss), but if concurrent with substance use disorders or psychotic occasionally excessive eating; and decreased energy, symptoms (Isometsa 2014). fatigue, multiple aches, and pains. People with depression frequently delay seeking pro- The cognitive symptoms may include thoughts of fessional treatment—particularly those with early-onset worthlessness and guilt, suicidal thoughts, difficulty cases (Olfson and others 1998)—and frequently receive Adult Mental Disorders 69 undertreatment. The WMH surveys found that the episode triggered by cues that act as reminders of the proportion of persons with mood disorders receiving trauma; disturbed sleep (including nightmares); and any treatment in the first year of onset of the dis- hyperarousal, such as exaggerated startle responses. order ranged from 6 percent in China and Nigeria to 52.1 percent in the Netherlands, with an IQR of Social Anxiety Disorder. Social anxiety disorder (social 16.0–42.7 percent. Overall, the use of mental health ser- phobia) is characterized by a persistent fear of social vices is lower in LMICs and largely corresponds to coun- situations or performance situations that expose a per- tries’ overall spending on health. A higher proportion son to potential scrutiny by others. It may be difficult to of people receives care from general medical services separate social anxiety disorder from extremes of normal (except in some countries, including Colombia, Israel, temperament, such as shyness. Nonetheless, social anxi- and Mexico), indicating the need to focus on inter- ety disorder can be quite disabling. ventions through general health care platforms (Wang, Aguilar-Gaxiola, and others 2007). Simple Phobias. Simple phobias are extreme fear in the presence of discrete stimuli or cues such as heights or spiders. Anxiety Disorders Clinical Features and Course Obsessive-Compulsive Disorder. Obsessive-compulsive Anxiety disorders represent symptomatically diverse, disorder (OCD) was historically considered an anxiety albeit related, forms of dysregulation of fear responses disorder, but is now recognized to reflect dysfunction in the brain, likely excessive activation of subcor- of a different brain circuit, striatal-thalamic-cortical tical fear circuitry with inadequate regulation by the loops (Pauls and others 2014). While OCD symptoms prefrontal cortex. In anxiety disorders, even innocu- engender severe anxiety, the core symptoms are intru- ous stimuli induce a significant and often prolonged sive, unwanted thoughts followed by actions and rituals response including tension, vigilance, activation of the meant to neutralize them. For example, the thought that sympathetic nervous system, subjective fear, and, in some a doorknob is contaminated may lead to excessive hand- circumstances, panic. washing. When severe, OCD rituals can consume much Although anxiety per se is likely to feature in the clin- time in the day and can be distressing and disabling. ical presentation of most patients, somatic complaints Childhood onsets are common and are more likely to be such as chest pain, palpitations, respiratory difficulty, or familial than later onsets. headaches are common. These symptoms may be more commonly reported in LMICs. Epidemiology and Burden of Disease Anxiety disorders are the most common mental disorders Panic Disorder. The central feature of panic disorder is in most of the countries that participated in the WMH an unexpected panic attack: a discrete period of intense surveys. The 12-month prevalence of anxiety disorders fear accompanied by physiological symptoms, such as a ranges between 3.0 percent (China) and 19.0 percent racing heart, shortness of breath, sweating, or dizziness, (the United States), with an IQR of 6.5–12.2 percent with an intense fear of losing control or dying. Panic (Kessler and others 2008). Despite wide variation in disorder is diagnosed when the attacks are recurrent and overall prevalence, specific phobia and social phobia are give rise to anticipatory anxiety about additional attacks. generally the most prevalent lifetime anxiety disorders, People with panic disorder may progressively restrict with a weighted mean prevalence of 6.4 percent and their lives and ultimately stop leaving their homes alto- 4.6 percent, respectively. Panic disorder and OCD are gether to avoid situations like crowds, traveling, bridges, generally the least prevalent, with weighted means of or elevators, in which panic attacks occur. 1.7 percent and 1.3 percent, respectively. Anxiety disorders have consistently been found in Generalized Anxiety Disorder. Generalized anxi- epidemiological surveys to be highly comorbid, both ety disorder is characterized by chronic, unrealistic among themselves (multiple anxiety disorders) and in and excessive worry, accompanied by anxiety-related combination with mood disorders. Most people with a symptoms such as sympathetic nervous system arousal, history of one anxiety disorder typically have a second excessive vigilance, and motor tension. anxiety disorder. More than half of the people with a history of either an anxiety or mood disorder typically Post-Traumatic Stress Disorder. PTSD follows signifi- have both types of disorders. Retrospective reports cant trauma and is characterized by emotional numb- from community surveys consistently show that anxiety ness, punctuated by intrusive reliving of the traumatic disorders have early average ages of onset, a median of 70 Mental, Neurological, and Substance Use Disorders approximately age 15 years, based on cross-national from those of people who have unipolar depression, but patterns (de Graaf and others 2003; Kessler, Chiu, and those with bipolar disorder tend to be less responsive to others 2005). treatment. Mixed states may occur, with symptoms of There is considerable delay in seeking care for anxi- both mania and depression. ety disorders. Data from the WMH surveys report that, The rate of cycling between mania and depression among the countries studied, the proportion of persons varies widely among individuals. One common pat- with anxiety disorders receiving treatment within the tern of illness is for episodes initially to be separated first year of the onset of the disorder ranged from 0.8 by a relatively long period, perhaps a year, and then to percent in Nigeria to 36.4 percent in Israel among the become more frequent with age. A minority of patients countries studied, with an IQR of 3.6–19.8 percent. with bipolar disorder has four or more cycles per year The median delay in seeking care varied significantly (Coryell and others 2003). These individuals tend to be between countries, ranging from three years in Israel to more disabled and less responsive to treatment. Once as many as 30 years in Mexico (Wang, Angermeyer, and cycles are established, acute relapses may occur without others 2007). an identifiable precipitant, with the exception of sleep Anxiety disorders have consistently been found in deprivation (Leibenluft and others 1996), making a epidemiological surveys to be associated with substantial regular daily sleep schedule and avoidance of shift work impairments in productive roles (such as work absen- important in disease management. teeism, work performance, unemployment, and under- employment) and social roles (such as social isolation, Epidemiology and Burden of Disease interpersonal tensions, and marital disruption). Bipolar disorder has an equal gender ratio. Retrospective reports from community epidemiological surveys con- sistently show that bipolar disorder has an early age of Bipolar Disorder onset in the late teens through mid-20s. Onset in child- Clinical Features and Course hood has been recognized (Geller and Luby 1997), but Bipolar disorder is defined by the presence of mania as well childhood diagnoses remain controversial; the revision as depression, but the relative frequency and duration of the in the recent Diagnostic and Statistical Manual of Mental two poles vary widely. Moreover, mixtures of symptoms are Disorders, 5th ed. (DSM-5) offers disruptive mood quite common. Patients with bipolar disorder have recur- dysregulation disorder as an alternative explanation of rent episodes of illness—manias and depression—and severe childhood mood disturbance with temper tan- may recover to baseline functioning between episodes. trums (APA 2013). However, many patients have residual symptoms, most Epidemiological surveys have consistently found often depressive symptoms, which may cause significant bipolar disorder to be highly comorbid with other impairment (Angst and Sellaro 2000). Individuals who psychiatric disorders, especially anxiety and substance have had at least one manic episode are considered to have use disorders (ten Have and others 2002). The extent bipolar disorder, even if they have not yet experienced a of comorbidity is much greater than for unipolar depressive episode. Some classification systems distinguish depressive disorders or anxiety disorders. Some indi- bipolar I disorder, in which patients meet the full criteria viduals with classical symptoms of bipolar disorder also for manic episodes, from bipolar II disorder, in which exhibit chronic psychotic symptoms superimposed on patients experience only mild manic episodes. their mood syndrome—and are then diagnosed with Mania is typically characterized by euphoria or irrita- schizoaffective disorder. Their prognosis tends to be less bility, a marked increase in energy, and a decreased need favorable than for the classical bipolar patient, although for sleep. Individuals with mania often exhibit impulsive somewhat better than for individuals with schizophrenia. and disinhibited behaviors. There may be excessive Schizoaffective disorder may also be diagnosed when involvement in goal-directed behaviors characterized chronic psychotic symptoms are superimposed on uni- by poor judgment. Self-esteem is typically inflated, polar depression. The latter have outcomes similar to frequently reaching delusional proportions. Speech is patients with schizophrenia (Tsuang and Coryell 1993). typically rapid and difficult to interrupt. Individuals A recent systematic review of 29 epidemiological with mania may exhibit cognitive symptoms; patients studies covering 20 countries reported 6- and 12-month cannot stick to a topic and may jump rapidly from idea point prevalence estimates of bipolar disorder of 0.74 to idea, making comprehension of their train of thought and 0.84 percent, respectively, with no significant differ- difficult. Psychotic symptoms are common during ences correlated with gender or economic status (Ferrari, manic episodes. The depressive episodes of people with Baxter, and Whiteford 2011). Notably, good evidence bipolar disorder are symptomatically indistinguishable exists that bipolar disorder has a wide subthreshold Adult Mental Disorders 71 spectrum that includes people who are often seriously that the prodrome is associated with excessive cortical impaired even though they do not meet full DSM or thinning, especially in prefrontal and temporal cortices International Classification of Diseases criteria for bipo- (Vidal and others 2006). Abnormal synaptic loss (prun- lar I or II disorders (Perugi and Akiskal 2002). This spec- ing) beginning in the prodrome is thought to cause trum might include as much as 5 percent of the general significant loss of neural processes and synapses, consis- population. The ratio of recent-to-lifetime prevalence tent with the significant observed cognitive impairment of bipolar disorder in community surveys is quite high (Lesh and others 2011). (0.71), indicating that bipolar disorder is persistent. The diagnosis of schizophrenia is generally made with Bipolar disorder is associated with substantial a first onset of florid psychotic symptoms. First episodes impairments in productive and social roles (Das Gupta of schizophrenia generally respond well to antipsychotic and Guest 2002), and there are consistent delays in ini- drugs, but the response attenuates over time. Ultimately, tially seeking professional treatment (Olfson and others most patients have residual psychotic symptoms and 1998), particularly among early-onset cases, and sub- acute psychotic relapses despite treatment. stantial undertreatment of current cases. Each of these The course of schizophrenia, beyond the first psy- characteristics—chronic, recurrent course; significant chotic episode, is typically one of relapses of severe impairments to functioning; and modest treatment psychotic symptoms, followed by partial remission. rates—contributes to the significant disease burden The time between relapses is extended by maintenance approaching that for schizophrenia. treatment with antipsychotic drugs at lower doses than are needed to treat acute episodes. Cognitive and occu- pational functioning tend to decline over the first years PSYCHOTIC DISORDERS: SCHIZOPHRENIA of the illness and then to plateau at a level well below what would have been expected for the individual (Lesh Clinical Features and Course and others 2011). Nonetheless, residual impairment has Schizophrenia is a severe neuropsychiatric syndrome substantial cross-cultural variation that is hypothesized associated with significant lifelong disability as well as to reflect greater maintenance of social integration in premature mortality from suicide and other causes. societies where outcomes are better. Schizophrenia exhibits three main symptom domains: Based on emerging genetic findings as well as obser- vation of symptom diversity, severity, and treatment • Psychotic, or positive, symptoms include hallucinations response, it is clear that schizophrenia is highly hetero- and delusions that are generally experienced as hav- geneous (Ripke and others 2014; Sullivan, Daly, and ing a basis in reality outside the person’s psyche. O’Donovan 2012). Schizophrenia is now seen as a spec- • Negative, or deficit, symptoms include loss of motiva- trum of disorders that includes both related nonaffective tion, blunted affect, and impoverishment of thought psychoses and likely some affective psychoses, such as and language. schizoaffective disorder, although the DSM-5 does not • Cognitive symptoms include significant impairments yet recognize this breadth (APA 2013). in attention, working memory, declarative memory, verbal fluency, and multiple aspects of social cogni- tion. In addition, many individuals with schizophrenia Epidemiology and Burden of Disease suffer from mood disturbances, usually depression. Schizophrenia affects between 0.5 and 1.0 percent of the population worldwide, with a male-female ratio Negative and cognitive symptoms, currently untreat- of 1.4 to 1.0 (McGrath and others 2004). Seven or eight able, are highly disabling, in great measure because of a persons per 1,000 are likely to be affected by schizo- loss of ability to control thought, emotion, and behavior phrenia in their lifetime. Point prevalence is estimated (Lesh and others 2011). Indeed, individuals with schizo- to be 4.6 per 1,000 persons (Saha and others 2005). phrenia remain disabled even when their positive symp- The incidence rates vary greatly by gender, urban toms are well controlled. status, and migrant status. A systematic review of 158 Schizophrenia typically begins in the mid-teen studies found a median incidence rate of 15.2 per years with a prodrome (also described as a psychosis 100,000 persons, with a 10 and 90 percent quantiles risk state) characterized by significant declines across range of 7.7–43.0. The incidence rate was found to be multiple cognitive domains, social isolation, odd and influenced by gender, with a higher incidence in men eccentric thinking, and later by attenuated psychotic (median male-female ratio of 1.4 to 1.0, with a 10 symptoms (Fusar-Poli and others 2013). Longitudinal and 90 percent quantiles range of 0.9–2.4). And there structural magnetic resonance imaging studies suggest was a higher incidence in migrants than native-born 72 Mental, Neurological, and Substance Use Disorders individuals (median migrant–native-born incidence from discrimination, and inspection of institutions. rate ratio of 4.6, with a 10 and 90 percent quantiles The WHO’s Assessment Instrument for Mental Health range of 1.0–12.8) (McGrath and others 2004). Systems (WHO-AIMS) survey in 2009 observed that Although schizophrenia is a relatively uncommon about 42 percent of all participating low-income coun- disorder, aggregate estimates of disease burden are high tries and 30 percent of the lower-middle-income coun- because the condition is associated with early onset, tries had legislation to protect people with mental long duration, and severe disability. Schizophrenia leads disorders against discrimination in employment, com- to loss of approximately 1,994 DALYs per one million pared with 80 percent of upper-middle-income coun- population (WHO 2014a). tries (WHO 2009). By means of action or inaction, legislation can itself contribute to human rights abuses. In the WHO-AIMS INTERVENTIONS FOR MOOD, ANXIETY, AND survey, LMICs reported higher frequency of involuntary PSYCHOTIC DISORDERS admissions to mental hospitals and other inpatient units, as well as higher incidences of human rights abuses in This section updates the evidence contained in Disease hospitals and many fewer provisions for inspections of Control Priorities in Developing Countries, 2nd ed., based health facilities (WHO 2009). on a systematic search of systematic reviews. Where no reviews were found, randomized controlled trials testing the effectiveness of interventions for mood, anxiety, and Community Platform Interventions psychotic disorders were included. Community-based interventions primarily seek to promote health and prevent illness in settings such as workplaces and schools, as well as within families and Population Platform Interventions other community networks. Mental Health Awareness Campaigns Awareness campaigns through mass media can be Workplaces instrumental in reducing prejudice (Clement and others Workplace attributes related to organizational culture, 2013) and improving the use of services (Grilli, Ramsay, employment status, exposure to workplace trauma, and Minozzi 2002). A community-based awareness and job dissatisfaction can contribute to psychosocial program in Nigeria was helpful in making mental disor- risk factors for mood disorders. Although largely drawn ders a priority on the local political agenda (Eaton and from studies in HICs, work-related stress management Agomoh 2008). through physical exercise and cognitive and behav- Awareness campaigns must attempt to dispel myths ioral approaches such as problem-solving techniques, and fight discrimination against people affected by meditation, and relaxation training can help prevent mental disorders while educating and increasing aware- and improve symptoms of anxiety and depression ness of mental disorders. Interventions based on edu- among employees (Martin, Sanderson, and Cocker 2009; cation and improvement of social contact with persons Penalba, McGuire, and Leite 2008). For employees with with mental disorders appear to be the most effective to diagnosed depression, collaboration among all parties increase knowledge, reduce stigma, change behavior, and dealing with the management of affected employees is decrease the “desire for social distance” (Evans-Lacko important. Provision of integrated care and access to and others 2012; Yamaguchi and others 2013). However, worksite stress reduction programs, with assured con- campaigns focused on increasing public understanding fidentiality for the employee, can reduce symptoms of of the biological correlates alone may not lead to bet- depression (Furlan and others 2012). ter social acceptance of people with mental disorders (Schomerus and others 2012). Experience from the mass Schools media interventions in the United Kingdom suggests Schools are a good platform for increasing community that it may be helpful to include messages on how to awareness about mental health. Evidence from a ran- help (Evans-Lacko and others 2010). domized controlled trial in rural Pakistan demonstrated that increasing mental health awareness among school Mental Health Legislation children also increased awareness among parents and Fewer than half of LMICs have enacted legislation focused neighbors (Rahman and others 1998). on mental health (WHO 2011). Where they exist, mental Preventive interventions, such as structured physical health laws focus on human rights protection, involun- activity, delivered in schools can reduce students’ anxiety tary admission and treatment, guardianship, freedom and improve self-esteem (Bonhauser and others 2005). Adult Mental Disorders 73 Similarly, programs that advance positive thinking have the symptoms of mood and anxiety disorders have been been effective in preventing depression in school chil- developed and subjected to well-designed clinical trials dren (Yu and Seligman 2002). As in workplace stress that have demonstrated their efficacy for depressive and reduction programs, psychological and educational anxiety disorders (Beck and Haigh 2014). Cognitive counseling can decrease anxiety among students (Sharif remediation therapies for schizophrenia are in the early and Armitage 2004). stages of development, but appear promising. Table 4.1 reviews the evidence for pharmacotherapy Family and psychotherapy for mood, anxiety, and psychotic dis- Family interventions through support groups or for- orders. Although the evidence that strongly supports the mal family therapies promote understanding of mental efficacy of a range of pharmacological and psychother- disorders among family members and support positive apeutic interventions is from HICs, the interventions family environments by reducing overinvolvement and have been validated in a wide range of cultures, ethnici- excessive criticism of affected members within families. ties, and levels of economic development. However, con- The ultimate goal is to reduce relapse and hospitalization textual adaptation of psychosocial interventions should events in patients and reduce the stress felt by family occur routinely. Integration with social welfare depart- members living with the patient. ments in LMICs could also be helpful in addressing the Family interventions—including brief interventions burden of life stressors in these settings. over a limited number of sessions—are effective for This substantial body of knowledge is relevant for schizophrenia (Okpokoro, Adams, and Sampson 2014; guiding treatment in nonspecialist health care plat- Pharaoh and others 2010) and bipolar disorder (Justo, forms in LMICs and has formed the basis of the Soares, and Calil 2007). Although there is a relative pau- recent WHO Mental Health Gap Action Programme city of high-quality studies on family interventions, it is (mhGAP) guidelines (WHO 2010). Unfortunately, this reasonable to utilize family interventions in the man- information is far too rarely applied in practice (Hyman agement of psychotic disorders, particularly in LMICs 2014; Simon and others 2004) despite implementation where most people with psychosis stay with families who research in LMICs that has sought to bridge the gap are also the primary caregivers. Existing interventions between what we know and what we do. These packages can be used with relevant adaptation of the therapies of care are described in the next section. according to the local social and cultural context. Specialist Care. Electroconvulsive therapy (ECT) is a well-established, effective, and relatively low-cost ther- Health Care Platform Interventions apy for adults with severe or treatment-resistant depres- Treatments for Mood and Psychotic Disorders sion, older people with depression (Martinez-Amoros Self-Care and Management. Self-care enables people and others 2012), and acute mania when a patient living with mental disorders to take the first step in effec- cannot tolerate medications. ECT must be administered tive prevention and management of their conditions. in a clinical setting with the help of qualified personnel Systematic reviews suggest that regular exercise pro- to deliver the treatment as well as anesthesia and muscle motes physical and mental well-being in individuals with relaxants. Once symptoms have improved (generally six depression (Cooney and others 2013) and psychoses to eight treatments delivered no more frequently than (Gorczynski and Faulkner 2010). Similarly, relaxation every other day), the person may receive antidepressant techniques (Jorm, Morgan, and Hetrick 2008) and medications. In treatment refractory cases, ECT is also music therapy (Maratos and others 2008) effectively used as a maintenance therapy for depression. reduce depressive symptoms. The use of media-delivered Combined with antipsychotic medications, ECT may psychotherapy interventions is effective for self-care also be an option for people with schizophrenia, partic- in persons with anxiety disorders (Mayo-Wilson and ularly when rapid global improvement and reduction of Montgomery 2013). For people with psychotic disorders, symptoms is desired as well as in cases with no response education forms a component of self-care: knowing early to medications, although it has only short-term benefits warning symptoms and signs of bipolar disorder and (Tharyan and Adams 2005). schizophrenia and their management has been found to Among the newer treatment modalities, transcranial improve functioning and delay recurrence, reducing the magnetic stimulation, which involves the use of a magnet need for hospitalization (Morriss and others 2007). to stimulate selected areas of the brain, may be effec- tive for refractory depression, but the evidence remains Pharmacotherapy and Psychotherapy. Many psycho- inconclusive. Moreover, it is expensive and limited in scal- therapies based on cognitive mechanisms underlying ability because of the need for the appropriate technology. 74 Mental, Neurological, and Substance Use Disorders Table 4.1 Review of Evidence for Pharmacologic and Psychological Treatment of Mood, Anxiety, and Psychotic Disorders Disorder First-line treatment Second-line treatments or adjunct treatment Mood disorders Depressive disorder • Antidepressants: • For postpartum depression: • Tricyclic antidepressants and selective serotonin reuptake • Psychological and social interventions (Dennis and inhibitors (Silva de Lima and Hotopf 2003; von Wolff and Hodnett 2007)a others 2013)a • SSRIs, but safety concerns for breastfeeding • Psychotherapy: neonates are not known (Molyneaux and others • Brief psychological interventions (Cuijpers and others 2014)a 2009)b • For psychotic depression: Combination of an • Problem-solving therapy (Cuijpers, van Straten, and antipsychotic and an antidepressant (Wijkstra and Warmerdam 2007; Huibers and others 2007)b others 2013)a • Cognitive behavioral therapy (Orgeta and others 2014; • For refractory depression: Wilson, Mottram, and Vassilas 2008)a • Combined CBT and antidepressant (Wiles and • Behavioral therapies (Shinohara and others 2013)a others 2013)c • Psychodynamic therapies (Abbass and others 2014)a • Electroconvulsive therapy (Martinez-Amoros and others 2012; UK ECT Review Group 2003)a • Interpersonal psychotherapy (de Mello and others 2005)a • Transcranial magnetic stimulation (Gaynes and others 2014)a Notes • Antidepressants are also effective for depression in people with physical illnesses (Rayner and others 2010).a • Antidepressants can be effectively prescribed in primary care settiings (Arroll and others 2009).a • Problem-solving therapy can be delivered by general practitioners (Huibers and others 2007).a • Group interpersonal therapy is effective in community-based, low-resource settings (Bass and others 2006).c • Older tricyclic antidepressants are similar in efficacy to newer drugs, but have greater side effects (Mottram, Wilson, and Strobl 2006).a • Continuation of treatment with drugs for 9–12 months following response to medication reduces the risk of relapse (Kaymaz and others 2008;b Wilkinson and Izmeth 2012a). • Evidence to suggest the superiority of one type of psychological intervention over another is limited (Cuijpers and others 2008;b Moradveisi and others 2013c). Bipolar disorder • Combination of second-generation antipsychotics and • Psychotherapies like CBT, group psychoeducational mood stabilizers for acute mania (Scherk, Pajonk, and therapy, and family therapy (Soares-Weiser and Leucht 2007)a others 2007)a • Lithium, valproate, lamotrigine, and olanzapine for maintenance therapy to prevent relapse (Soares-Weiser and others 2007)a Anxiety disorders Anxiety disorders • Antidepressants (Kapczinski and others 2003)a Generalized anxiety disorder • CBT-based psychotherapies (Hunot and others 2007)a Panic disorder • Combined therapy (CBT and antidepressants) or CBT alone (Furukawa, Watanabe, and Churchill 2007)a Post-traumatic stress • No psychological intervention can be recommended routinely • Non-trauma focused CBT and eye movement disorder following traumatic events, and this may also have adverse desensitization and reprocessing (Bisson and others effects on some individuals (Roberts and others 2009). 2013)a • SSRI antidepressants (Stein, Ipser, and Seedat 2006)a • CBT (particularly trauma-focused CBT) (Roberts and others 2010) table continues next page Adult Mental Disorders 75 Table 4.1 Review of Evidence for Pharmacologic and Psychological Treatment of Mood, Anxiety, and Psychotic Disorders (continued) Disorder First-line treatment Second-line treatments or adjunct treatment Notes • There is no conclusive evidence of greater effectiveness of combined pharmacotherapy and psychotherapy over either of them alone for PTSD (Hetrick and others 2010).a Schizophrenia • First-generation antipsychotics, such as haloperidol and • CBT as adjunctive treatment for positive symptoms fluphenazine, for positive symptoms (Tardy, Huhn, Engel, and (Zimmermann and others 2005)b Leucht 2014; Tardy, Huhn, Kissling, and Leucht 2014)a • Cognitive remediation therapies, in early stages of • Combination of antipsychotics and antidepressants is effective the disorder (Fisher and others 2013)d for negative symptoms (Rummel, Kissling, and Leucht 2006).a • Psychoeducation reduces relapse, readmission, • Second-generation antipsychotics (amisulpride, clozapine, and length of hospital stay while encouraging olanzapine, and risperidone). These are superior to first- medication compliance (Xia, Merinder, and generation antipsychotics in efficacy and have different side- Belgamwar 2011).a effect profiles (Leucht and others 2009).a • Psychosocial interventions for reducing the need for antipsychotic medications (Richter and others 2012)a • Clozapine for refractory schizophrenia but needs monitoring for side effects (Essali and others 2009)a Notes • Continued antipsychotic medication following a clinical response helps prevent relapse (Leucht and others 2012; Sampson and others 2013).a • Acetylcholinesterase inhibitors are effective to overcome anticholinergic side effects of antipsychotic drugs (Leucht and others 2012).a • Evidence for clear and convincing advantage for CBT over other therapies is limited (Jones and others 2012).a Note: CBT = cognitive behavioral therapy; PTSD = post-traumatic stress disorder; SSRI = selective serotonin reuptake inhibitor. a. Systematic review. b. Meta-analysis. c. Randomized controlled trials in low- and middle-income countries. d. Review. Persons with severe mental illnesses occasion- with severe mental illnesses (Kinoshita and others 2013). ally require short periods of hospitalization and/or Systematic reviews have shown that life skills and social longer-term supported housing because of the severity of skills training have moderate to strong effectiveness their disorders and associated behaviors or abandonment to promote integration of persons with severe mental by family. Systematic reviews have suggested that acute illnesses in communities where they live; and interven- day hospitals can be as effective as inpatient care (Marshall tions with a greater client-centered approach have a and others 2011) and that day hospitals may prevent the larger impact (Gibson and others 2011). need for inpatient care (Shek and others 2009). Packages of Care Occupational Therapy. Occupational therapy inter- Promotion and Prevention. Indicated or targeted ventions aim to support and improve skills for daily prevention of mental disorders is effective in the living through life skills training, cognitive rehabilita- early and subclinical stages. A meta-analysis of 32 tion, supportive employment and education, and social studies (largely from Europe and the United States) and interpersonal skills training. Occupational therapy concluded that preventive interventions could lower is effective in rehabilitating persons with depression by the incidence of depression by 21 percent through increasing productivity, reducing work-related stress, psychological interventions such as cognitive behav- and helping in recovery (Hees and others 2013; Schene ioral therapy (CBT), interpersonal therapy, individual and others 2007). Supported employment is effective in counseling, and group sessions (van Zoonen and improving a number of vocational outcomes in persons others 2014). Psychological treatment of subclinical 76 Mental, Neurological, and Substance Use Disorders depression was shown to have some effect in prevent- a randomized controlled trial in India (Chatterjee and ing the onset of major depression after six months others 2014). (Cuijpers and others 2014). Key principles of the collaborative model include For people with early psychosis, early intervention proactive case detection; a structured management plan; services (including CBT and family interventions) patient education; systematic monitoring and follow-up; appear to have clinically important benefits over stan- and close collaboration among the patient, a case man- dard care, but the longer-term benefits of this approach ager, primary care providers, and specialists. Successful remain unclear (Bird and others 2010; Marshall and implementation of such a model, however, depends on Rathbone 2011). Specifically designated early interven- trained primary care staff, clear protocols and guidelines, tion teams are in place in many HICs, but LMICs have and specialist supervision and support in the imple- few programs and no formal evaluations. mentation of the guidelines (Patel and others 2013). Notably, the case manager’s role is critical: this person Case Detection and Diagnosis. The WHO advocates acts as the link between the patient or the patient’s fam- symptom-based algorithms for the detection of mental ily, the primary care physician, and the specialist, and disorders by nonspecialized health care providers in undertakes proactive case detection, monitors progress, general medical service settings (WHO 2008, 2010). and provides psychosocial interventions and adherence Cultural influence on the clinical presentation of men- support (if medication is prescribed). The case manager tal disorders should be accounted for in case detection could also be an appropriately trained and supervised and screening programs. For example, the inclusion of lay counselor or community health worker. Compelling unexplained somatic symptoms in screening for anx- evidence from LMICs suggests that community health iety and depression might improve case detection in workers, nonspecialized health workers, and parapro- LMICs. Training and screening for detection of mood fessionals, based in primary care or community settings, and anxiety disorders in primary care settings are can detect cases (Patel and others 2008) and effectively being implemented globally; however, screening must deliver psychosocial interventions for depressive disor- be accompanied by health system changes to ensure der, postpartum depression, and PTSD (den Boer and clinical benefits for patients by allowing sustained access others 2005; van Ginneken and others 2013). to evidence-based treatments (Gilbody, House, and Sheldon 2005; Kauye, Jenkins, and Rahman 2014; Patel Community Outreach for Severe Mental Disorders. and others 2009). The WHO’s mhGAP intervention guidelines for pro- When appropriately trained, health workers can iden- viding mental health care in nonspecialized settings in tify probable cases of rare disorders such as schizo- LMICs explicitly include revival of social networks and phrenia, although community case-finding should be participation in community activities as a part of treat- confirmed with diagnostic interviews (de Jesus and ment and care for patients with depression, anxiety, and others 2009). psychosis (WHO 2010). Community mental health teams that include Collaborative and Stepped Care. Collaborative care is outreach workers can effectively manage severe an approach to the care of chronic illnesses that has been mental illnesses with greater acceptance and fewer successfully implemented for management of mental hospital admissions and suicides (Malone and others disorders in primary care. These models emphasize self- 2007). A systematic review of trials from HICs suggests care and care management, blended with other phar- that intensive case management, based on an asser- macotherapeutic, psychotherapeutic and specialist care tive community care model that involves providing interventions, and community supports. Specifically, the community-based care for people with severe mental model adopts a patient-centric approach and includes illnesses, focusing on the health and social care needs of active collaboration with mental health professionals, the patients by a team of trained health workers, leads to so that patients with severe disorders receive specialist a reduced need for hospitalization, increased retention intervention. in care, and improved social functioning (Dieterich Collaborative care for depression and anxiety dis- and others 2010). Randomized controlled trials in the orders is associated with significant improvement in United Kingdom also show that crisis interventions clinical outcomes and leads to improvement in adher- delivered by a trained team can provide acceptable care ence, patient satisfaction, and mental health quality of to people with severe mental illnesses during the crisis life (Archer and others 2012; Patel and others 2009). phase, improve short-term mental health outcomes, Collaborative care can also be effective for severe mental reduce repeat admissions, and provide greater satisfac- illnesses (Reilly and others 2013), as demonstrated in tion for patients and families (Murphy and others 2012). Adult Mental Disorders 77 Longitudinal studies from India have observed that However, a few clinical trials have been conducted community-based rehabilitation for people with psy- in LMICs that included an economic evaluation. These chotic disorders have a beneficial impact on disabil- demonstrated not only the feasibility, but also the infor- ity (Chatterjee and others 2009). Recently published mational value of such analyses (Araya and others 2006; results from a clinical trial in India also suggest that Buttorff and others 2012; Patel and Kleinman 2003). community-based care along with facility-based care is Explaining that a depression-free day could be gained for more effective than facility-based care alone for reducing the price of a bus ticket, for example, was a helpful argu- disability and symptoms due to psychoses (Chatterjee ment in the roll-out of depression care in Chile (Araya and others 2014). Close participation of families, and others 2006). In India, the MANAS (MANashanti community members, and local health providers, in con- Sudhar Shodh, or project to promote mental health) cert with continuous treatment, form the foundation of trial showed that a task-shifting intervention for com- community-based care and rehabilitation. Activities to mon mental disorders was not only cost-effective, but facilitate economic and social rehabilitation (Chatterjee also cost-saving when time costs were taken into consid- and others 2003)—such as supported housing for people eration (Buttorff and others 2012). with severe mental illnesses (Chilvers, Macdonald, and Partly because of the lack of available primary data, Hayes 2006) and vocational rehabilitation (Crowther several cost-effectiveness modeling studies have been and others 2001)—are effective in promoting rehabilita- conducted, at the national and international levels. tion of people with severe mental disorders. These studies, which rely on secondary data to generate estimates of expected cost and health gain, are reviewed Information and Communication Packages. in chapter 12 in this volume (Levin and Chisholm Information and communications technology (ICT) 2015). Overall, the studies indicate that, depending on is emerging as a promising tool for providing care for the particular context and content of the interventions, people with mental disorders. The diverse technolo- cost-effectiveness ranges between US$100 and US$2,000 gies under this umbrella, along with the considerable per healthy life year gained. Chapter 13 in this volume presence of mobile phones and Internet access in most (Chisholm and others 2015) applies an extended cost- LMICs, make outreach and delivery of personalized effectiveness analysis approach to several adult mental interventions feasible. These technologies can also be disorders (psychosis, bipolar disorder, and depression) effectively used to deliver interventions for self-care. to assess the distribution of costs and health gains across Telemedicine is effective in reaching out to rural and different income groups in the population, as well as remote areas (Pyne and others 2010), and can be pro- the financial protection effects of scaled-up care and vided effectively for the management of anxiety, depres- treatment. The analysis indicates that universal pub- sion, and psychotic disorders (Thara, John, and Rao lic finance can lead to a far more equitable allocation 2008). Telephones and other Internet-based applications of public health resources, with lower-income groups can be used to deliver health messages and prompts and benefitting most from enhanced financial protection peer support interventions, as well as evidence-based (Chisholm and others 2015). psychotherapies such as cognitive behavior therapy (Andersson and Cuijpers 2009). CONCLUSIONS AND RECOMMENDATIONS Mood disorders, anxiety disorders, and psychotic disor- COST-EFFECTIVENESS OF INTERVENTIONS ders are a diverse group of adult mental disorders that The preceding review reveals a diverse array of inter- are highly disabling and are caused by a complex interac- vention approaches and models that can be utilized tion of genetic, developmental, and environmental risk at different levels of the health (and welfare) system factors. These disorders are highly stigmatized in most for the prevention and management of adult mental countries and cultures and often lead to shame and fear disorders, and includes an increasing body of evidence of rejection and discrimination. from and for settings in LMICs. However, the availabil- The good news is that awareness campaigns, particu- ity of cost-effectiveness information to complement larly those involving engagement with people with men- this large and growing evidence base on effectiveness tal disorders, can improve general knowledge about these remains comparatively sparse. There is currently no disorders. Appropriate legislation also can address the cost-effectiveness evidence from LMICs relating to men- discrimination and human rights abuses that result from tal health awareness campaigns, family interventions, or social stigma. 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Patients neurological disorders included in the Global Burden of with neurological disorders often require significant social Disease (GBD) Study–Alzheimer’s and other dementias, and economic support because of physical, cognitive, and Parkinson’s disease, multiple sclerosis, epilepsy, and head- psychosocial limitations (WHO 2006). Despite the high ache disorders (migraine, tension-type headache [TTH], prevalence of disability, there is increasing recognition and medication-overuse headache [MOH])–represent 3 that services and resources are disproportionately scarce, percent of the worldwide burden of disease. Although this especially in LMICs (WHO 2004). In addition, knowledge is a seemingly small overall percentage, dementia, epilepsy, of the cost-effectiveness of interventions to improve neu- migraine, and stroke rank in the top 50 causes of disability- rological care in these settings remains limited. adjusted life years (DALYs) (Murray and others 2012). This chapter addresses three neurological disorders: Migraine and epilepsy represent one-third and one- epilepsy, dementia, and headache disorders. The chapter fourth of this neurological burden, respectively (Murray reviews current knowledge of the epidemiology, risk and others 2012), and dementia and Parkinson’s disease factors, and cost-effective interventions for these condi- are among the top 15 conditions with the most substan- tions. The focus is on interventions that provide mean- tial increase in burden in the past decade. In 2010, neu- ingful reduction in the burden to the global population, rological disorders constituted 5.5 percent of years lived with particular emphasis on applicability to LMICs. with disability (YLDs), or 42.9 million YLDs; migraine, Neurological disorders are an emerging challenge to epilepsy, and dementia were among the top 25 causes of health care systems globally, requiring further study, YLDs. Migraine leads the list of neurological disorders, government and social engagement, and improvements representing more than 50 percent of neurological YLDs in health care infrastructure. or 2.9 percent of global YLDs; epilepsy represents 1.1 This chapter uses the World Health Organization percent of global YLDs (Vos and others 2012). (WHO) regions—African, the Americas, Eastern The neurological burden of disease is expected to Mediterranean, European, South-East Asia, and Western grow exponentially in low- and middle-income countries Pacific—to describe the global burden of the high- (LMICs) in the next decade (Murray and others 2012). lighted neurological disorders. Despite the significant impact of neurological disorders Corresponding author: Tarun Dua, MD, MPH Programme for Neurological Diseases and Neuroscience Evidence, Research and Action on Mental and Brain Disorders, Department of Mental Health and Substance Abuse, World Health Organization; duat@who.int. 87 EPILEPSY Epidemiology and Burden of Disease Definitions A worldwide systematic review of prevalence has not yet been published; in general, the prevalence Epilepsy is a brain disorder traditionally defined as the in door-to-door studies has been reported to range occurrence of two unprovoked seizures occurring more from 2.2 per 1,000 to 41.0 per 1,000 persons, often than 24 hours apart with an enduring predisposition to with higher estimates in LMICs (Banerjee, Filippi, and generate further seizures (Fisher and others 2014). In Allen Hauser 2009; Benamer and Grosset 2009; Burneo, 2014, the International League against Epilepsy provided Tellez-Zenteno, and Wiebe 2005; Forsgren and others an enhanced definition of epilepsy (box 5.1). 2005; Mac and others 2007). The median incidence per Epilepsy is considered to be resolved if a person has 100,000 per year is higher in LMICs at 81.7 (interquartile an age-dependent syndrome that is now beyond the range (IQR) 28.0-239.5) compared with HICs at 45.0 expected age for this syndrome, or if the individual (IQR 30.3-66.7) (Ngugi and others 2011). remained seizure free for the past 10 years and was off The higher estimates of prevalence or incidence anti-epileptic drugs for at least the past five years (Fisher rates reported in many LMICs are thought to be and others 2014). Those who continue to have seizures caused by the occurrence of endemic conditions, such despite an adequate trial of a regimen of two tolerated as malaria or neurocysticercosis; the higher incidence and appropriately chosen anti-epileptic drugs (AEDs), of road traffic injuries; birth-related injuries; and whether in monotherapy or polytherapy, are considered variations in medical infrastructure, availability of to be drug resistant. Epilepsy can be classified in three preventative health programs, and accessible care. In categories: HICs, the prevalence of epilepsy is stable until after age 50, when it increases; in contrast, the prevalence • Structural or metabolic epilepsies, for example, in LMICs tends to be stable in the third and fourth epilepsy caused by a remote stroke decade of life, drops in the fifth decade, and, in some • Epilepsies of genetic or presumed genetic origin, for studies, increases again after age 60 (Banerjee, Filippi, example, juvenile myoclonic epilepsy and Allen Hauser 2009). • Epilepsies of unknown causes (Berg and others 2010). Epilepsy is associated with premature mortality, with the highest standardized mortality ratio encoun- Examples of more common causes of epilepsy tered in the first year or two after diagnosis (Neligan include brain tumors, infectious diseases, brain injury, and others 2010). In general, the standardized mor- stroke, and hippocampal sclerosis. Less frequent causes tality ratio for epilepsy is approximately 3 (Hitiris include genetic causes, autoimmune causes, and mal- and others 2007). The epidemiology of premature formations of cortical development (Bhalla and others mortality is particularly relevant in LMICs, where 85 2011). Perinatal and infection-related etiologies often percent of those with epilepsy live and where the risk of predominate in LMICs. premature mortality is highest (Diop and others 2005; Jette and Trevathan 2014; Newton and Garcia 2012). Most concerning is the fact that a greater proportion of deaths in LMICs are potentially preventable, such as Box 5.1 falls, drowning, burns, and status epilepticus (Diop and others 2005; Jette and Trevathan 2014). For example, 38 percent of all epilepsy-related deaths in a large cohort Definition of Epilepsy of people with convulsive epilepsy in rural Kenya A person has epilepsy if he or she meets any of the follow- were caused by status epilepticus (Ngugi and others ing criteria (Fisher and others 2014): 2014). Status epilepticus is defined as ongoing seizure activity lasting five minutes or more, or two or more seizures without recovery of consciousness in between • At least two unprovoked (or reflex) seizures occurring (Lowenstein and others 2001). This is an important more than 24 hours apart definition, as evidence suggests that seizures lasting • One unprovoked (or reflex) seizure and a probability more than five minutes are unlikely to self-terminate. of further seizures similar to the general recurrence Other common causes of premature mortality in those risk (at least 60 percent) after two unprovoked seizures, with epilepsy include acute symptomatic disorders (for occurring over the next 10 years example, brain tumor or stroke), sudden unexpected • Diagnosis of an epilepsy syndrome. death in epilepsy, suicide, and accidents (Hitiris and others 2007). 88 Mental, Neurological, and Substance Use Disorders Epilepsy ranks as the 36th leading cause of DALYs this study was US$1.33 million, although an economic globally, according to the GBD 2010 report. Epilepsy analysis was not conducted to determine if it was ranks as high as the 14th leading cause of DALYs in cost-effective. western Sub-Saharan Africa. Epilepsy ranks as the 20th A smaller-scale study examined the efficacy of leading cause of YLDs globally, second only to migraine teaching methods to prevent epilepsy caused by neuro- for brain disorders (Vos and others 2012). Importantly, cysticercosis in western Kenya (Wohlgemut and others models in the GBD 2010 report that calculate the 2010). The authors found that knowledge improved global burden of epilepsy consider only the previously significantly using this teaching method. Whether this termed idiopathic/cryptogenic epilepsy and not epilepsy program reduced the incidence of epilepsy caused by secondary to causes such as infections, stroke, or genetic taenia solium was not examined, but the findings rep- syndromes, which may be responsible for more than resent a positive step. The expert consultation report 50 percent of the deaths in these regions (Murray and on foodborne infections, such as taeniasis/cysticerco- other 2012). Therefore, the data likely underrepresent sis, proposes some approaches to ensure sustainable the true burden of epilepsy, especially in LMICs. prevention and control of this often endemic agent. These approaches are listed in box 5.2; however, the report did not define the costs of implementing these Interventions approaches (WHO 2011). Population-Based Interventions Targeting Epilepsy Risk Factors. Although genetic causes Anti-Stigma Interventions. Civil rights violations, of epilepsy cannot be prevented, the more common struc- such as unequal access to health and life insurance or tural or metabolic causes can be the target of primary prejudicial weighting of health insurance provisions, prevention through public health policies. For example, are common. Discrimination in the workplace and helmet use for motorcyclists and laws against drink- restricted access to education are frequent. School ing and driving can reduce the risk of traumatic brain teachers often have poor knowledge and negative atti- injury, a common risk factor. Improved perinatal care, tudes toward children with seizure disorders (Akpan, particularly in rural areas, can reduce the incidence and Ikpeme, and Utuk 2013). Stigma is associated with subsequent prevalence of epilepsy. In one Tanzanian social and economic consequences. Persons with epi- community-based, case-control study, adverse perinatal lepsy may not seek treatment or convey related health events were present in 14 percent of children with epilepsy concerns to their care providers, further widening the but absent in all controls (Burton and others 2012). A treatment gap. population-based cross-sectional and case-control study Improved knowledge about epilepsy is associated in Ghana, Kenya, South Africa, Tanzania, and Uganda with positive attitudes and reduced stigma, but the reported an association between abnormal antenatal period and active convulsive epilepsy (Ngugi and others 2013). Although abnormal delivery and home delivery did not reach statistical significance, there was a trend for Box 5.2 these to be associated with active convulsive epilepsy. Policies to control neurocysticercosis, a common Approaches to Ensure Sustainable Prevention and risk factor in LMICs, would be an effective way to Control of Neurocysticercosis reduce epilepsy worldwide. An extensive eight-year public health and educational intervention program • Preventive chemotherapy of human taeniasis through aimed at reducing symptomatic epilepsies (particularly mass or targeted treatment of humans those caused by perinatal insults and neurocysticerco- • Mass treatment and vaccination of pigs sis) was implemented in rural Salama, Honduras, • Community education in health and pig husbandry starting in 1997 (Medina and others 2011). The pro- • Improved sanitation to end open defecation gram included education and media campaigns, ani- • Improved meat inspection, control, and handling mal husbandry training for pig farmers, construction • Better pig management. of water projects and proper sewage disposal, deworm- ing of school students, ongoing taeniasis surveillance, The costs of implementing these approaches are not well and other initiatives (Medina and others 2011). The defined. proportion of epilepsy caused by neurocysticercosis Source: WHO 2009a. was reduced from 36.9 percent in 1997 to 13.9 percent in 2005 (Medina and others 2011). The overall cost of Neurological Disorders 89 sustainability and impact remain to be determined Pharmacological Interventions (Fiest and others 2014). A broad approach is needed to The decision to initiate treatment with anti-epileptic target stigma at the population level through legislation drugs can be challenging. Analysis of the Multicentre and advocacy. In addition, education and information trial for Early Epilepsy and Single Seizures suggests provision to dispel myths and enhance seizure manage- little benefit in initiating treatment for those who pres- ment among employers and teachers should empower ent with a single seizure, with no known neurological those with epilepsy to seek treatment and encourage disorder, and normal electroencephalograms (EEGs) them to be more actively engaged in their communities. (Kim and others 2006). However, medical management The cost-effectiveness of interventions to reduce stigma should be considered in those who are at moderate to has not been formally assessed. high risk, defined as more than two to three seizures at presentation, underlying neurological disorders, and Legislation. One of the greatest contributors to the epi- abnormal EEGs (Kim and others 2006). More than 60 lepsy treatment gap in LMICs is the lack of availability randomized control trials (RCTs), mostly in HICs, have of anti-epileptic drugs. The second-generation medica- examined the efficacy of anti-epileptic drugs, but there tions are not available in the majority of countries, and continues to be a lack of well-designed RCTs examining even the older anti-epileptic drugs are only available the efficacy of these medications for patients with gener- sporadically. Investigators in Zambia who surveyed alized epilepsy syndromes and for children (Glauser and 111 pharmacies found that 49.1 percent did not carry others 2013). Newer AEDs tend to be better tolerated, anti-epileptic drugs. Pediatric syrups that are extensively with fewer long-term side effects, but otherwise their used in HICs were universally unavailable (Chomba and superiority has not been proven. others 2010). Regrettably, personal communications Studies comparing the cost-effectiveness of anti- with epilepsy care providers in other LMICs suggested epileptic drugs in new onset epilepsy have not been that this problem may be widespread (Chomba and conducted. A recent systematic review summarizes the others 2010). evidence regarding their efficacy as initial monotherapy Clearly, policies are warranted to guarantee the in those with epilepsy. Monotherapy with any of the ongoing availability of affordable and efficacious standard anti-epileptic drugs (carbamazepine, pheno- anti-epileptic drugs to patients worldwide. Few coun- barbital, phenytoin, and valproic acid) should be offered tries have a separate budget for epilepsy services, and to children and adults with convulsive epilepsy. Several national funding support for epilepsy care is needed. lower-quality studies have demonstrated efficacy for Out-of-pocket expenses are the primary source of phenobarbital in adults and children with partial onset financing epilepsy care in 73 percent of low-income seizures and generalized onset tonic-clonic seizures countries, including many countries in Africa, the (Glauser and others 2013). Given the acquisition costs, Eastern Mediterranean, and South-East Asia, where the phenobarbital should be offered as a first option if burden is highest (WHO 2011). Disability benefits do availability can be ensured. If available, carbamazepine not exist in many regions, and patients are unable to should be offered to children and adults with partial receive monetary support. onset seizures (WHO 2009b). Using the lowest possi- ble dose should minimize side effects, improve seizure Self-Management outcomes, and decrease the treatment gap. Valproic acid Self-management is empowering patients to partici- and ethosuximide have been shown to be most effec- pate more actively in managing their care. Patients are tive in the management of absence seizures, especially likely to improve their understanding, adopt health- in children, although valproic acid is recommended, ier lifestyles, and improve adherence to treatment as it is on the list of essential medicines. Ethosuximide (Fitzsimons and others 2012). Self-management can is available as a complementary medication. However, help those with epilepsy better identify and manage the medication should be avoided, when possible, in their seizure triggers, which can reduce frequency and women of childbearing potential because of its higher decrease health services utilization and health care association with major congenital malformations and costs (Fitzsimons and others 2012). A few studies have poorer neurodevelopmental outcomes. Although newer examined the effectiveness of self-management edu- therapeutic agents that are not metabolized by the liver cation programs in adults and children and demon- are available, such as levetiracetam, the cost-effectiveness strated some evidence of benefits; future research is of such therapies has not been studied in LMICs. needed to examine the cost-effectiveness of such pro- Unfortunately, in LMICs, the availability and afford- grams in LMICs (Bradley and Lindsay 2008; Lindsay ability of standard medications are poor and constitute and Bradley 2010). barriers to treatment. One study found that the average 90 Mental, Neurological, and Substance Use Disorders availability of generic medications in the public sector is Surgical Management less than 50 percent for all medicines, except diazepam The probability of achieving one-year seizure freedom injection. The private sector availability of generic oral after trying up to three anti-epileptic drugs occurs in the medications ranged from 42 percent for phenytoin majority of cases (70 percent in those presenting with to 70 percent for phenobarbital. Public sector patient new onset epilepsy). However, drug resistance occurs prices for generic carbamazepine and phenytoin were 5 in up to 40% of patients overall, particularly in those and 18 times higher than international reference prices, with focal epilepsy (Berg and others 2009; Kwan and respectively; private sector patient prices were 11 and 25 Brodie 2000; Schiller and Najjar 2008; Semah and oth- times higher, respectively. For both medicines, originator ers 1998). In those who have failed three anti-epileptic brand prices were about 30 times higher. The highest drugs, attempting to treat with additional anti-epileptic prices were observed in the lowest-income countries drugs is unlikely to achieve sustained seizure freedom (Cameron and others 2012). Ensuring a consistent sup- (Jette, Reid, and Wiebe 2014). Experts generally agree ply at affordable prices should be a priority. that those who are drug resistant and have failed two Approximately 60 percent of patients in Sub-Saharan appropriate AED trials should be considered for a Africa do not have access to AEDs, increasing the risk of surgical evaluation (Jette, Reid, and Wiebe 2014; Kwan seizures, accidents related to seizures, and status epilep- and others 2010; Wiebe and Jette 2012). Other patients ticus, a significant cause of morbidity and mortality in who should be referred to a comprehensive epilepsy patients with epilepsy (Ba-Diop and others 2014). Some program for a surgical evaluation include children with of the best patient-related strategies to avoid status epi- complex syndromes, patients with stereotyped or lat- lepticus include adherence to treatment and avoidance eralized seizures or focal findings, and children with a of other seizure triggers. On a population level, the best magnetic resonance imaging lesion amenable to surgical way to avoid the morbidity and mortality associated with resection regardless of seizure frequency (Jette, Reid, status epilepticus is through health policy to increase the and Wiebe 2014; Wiebe and Jette 2012). Strategies for availability of and access to AEDs, and through health surgical therapy of epilepsies in resource-poor settings professional education such that health professionals are have been proposed, and epilepsy surgery is increasingly aware that time is brain. Aggressive treatment of status performed in LMICs, with excellent outcomes (Asadi- epilepticus should be implemented after five minutes, Pooya and Sperling 2008). not after 30 minutes of ongoing seizures, in accordance with the current operational definition of status epilep- Alternative Therapies ticus (Lowenstein and others 2001). Proposed alternative therapies for epilepsy include dietary therapies, medical marijuana, and acupuncture; Management of Infectious Etiologies of Epilepsy only dietary therapies have been subjected to random- Neurocysticercosis is a common cause of epilepsy in ized trials. The ketogenic diet can improve seizure LMICs. Recent evidence-based guidelines are available outcome in those with drug-resistant epilepsy, but is to guide the treatment of parenchymal neurocysticer- difficult to tolerate, particularly in adults (Levy, Cooper, cosis (Baird and others 2013). These guidelines suggest and Giri 2012). The Atkins diet was associated with that therapy with albendazole, with or without corti- improved seizure control in one observational study, costeroids, along with AEDs, is likely to be effective in but future studies are required to examine its benefit improving outcomes (Baird and others 2013). and the benefit of other dietary therapies, such as the Evidence-based guidelines were published to guide modified Atkins diet and the low glycemic index diet the selection of anti-epileptic drugs for people with (Levy, Cooper, and Giri 2012). Despite their increased HIV/AIDS, because concomitant AED-antiretroviral use, dietary therapies are resource intensive, costly, and administration may be indicated in up to 55 percent remain largely limited to HICs (Cross 2013). Cost- of people (Birbeck and others 2012). The guidelines effective and simpler means of implementing these state that it may be important to avoid enzyme- therapies in LMICs are needed. The efficacy of oral inducing AEDs in people on antiretroviral regimens cannabinoids and acupuncture for the treatment of that include protease inhibitors or nonnucleoside epilepsy remains uncertain (Cheuk and Wong 2014; reverse transcriptase inhibitors, because pharmacok- Koppel and others 2014). inetic interactions may result in virologic failure. If such regimens are required for seizure control, Interventions to Optimize Health Care Delivery patients may be monitored through pharmacokinetic The treatment gap is defined as the number of people assessments to ensure the efficacy of the antiretroviral with active epilepsy who need appropriate anti-epileptic regimen (Birbeck and others 2012). treatment but do not receive adequate medical therapy. Neurological Disorders 91 Regrettably, those living in LMICs, where the bur- can be trained to provide basic treatment. Patient- den of epilepsy is extensive, are the most affected related potential mechanisms for the treatment gap by the epilepsy treatment gap (Jette and Trevathan include cultural beliefs, stigma, fear of side effects, 2014). The treatment gap is more than 75 percent in the hassle factor, and cost of treatment (Cameron and low-income countries, more than 50 percent in many others 2012; Kale 2002; Mbuba and others 2008). All LMICs and upper-middle-income countries, and less these reasons for the epilepsy treatment gap should than 10 percent in most HICs (figure 5.1) (Meyer and be considered as potential targets for evaluation and others 2010). action. Proposed mechanisms for the epilepsy treatment One study examined the availability, price, and afford- gap can be divided into two broad categories: health ability of anti-epileptic drugs in 46 countries (Cameron care system and patient-related reasons (Cameron and others 2012). The study found that not only is and others 2012; Kale 2002; Mbuba and others 2008). the availability of these medications lower in LMICs, Health care system issues include lack of availability but their costs are highest where the treatment gap is of anti-epileptic drugs, missed or delayed diagnosis, the greatest (Cameron and others 2012). This study wrong treatment prescribed, treatment not offered supports the view that availability and affordability of to patients, and lack of resources and personnel anti-epileptic drugs are likely major drivers in resource- (Cameron and others 2012; Kale 2002; Mbuba and poor countries. Box 5.3 provides a summary of the others 2008). Epilepsy diagnosis is predominantly potential targets for evaluation and action to improve based on clinical history, and primary care physicians the epilepsy treatment gap. Figure 5.1 Epilepsy Treatment Gap and Standard Errors Calculated from Lifetime Prevalence Estimates 100 80 Treatment gap (%) 60 40 20 0 a sh an ia bia ica ka ina on la e ds s ain e ly te i nc or liv Ind ma Ita de an lan t ro ma lom Ch Sp ta kis ap Fra Bo me la iL te dS er ng Pa Ja ng Co a Sr th Ca Gu Si ite Ba Ne Un Low income Lower-middle income High income Urban or mixed Rural Children only Standard error Source: Meyer and others 2010. 92 Mental, Neurological, and Substance Use Disorders Two of the most impactful approaches to target the treatment gap are legislative and anti-stigma interven- Box 5.3 tions. Unfortunately, their cost-effectiveness has not been evaluated. Potential Targets to Improve the Epilepsy Treatment Gap Cost-Effectiveness of Interventions The cost-effectiveness literature is focused on the phar- Health Care System macological management of seizures, meaning that • Improve access to anti-epilectic drugs economic evidence concerning interventions at the pop- • Improve training of health care professionals to decrease ulation and community levels, such as stigma reduction the proportion of misdiagnoses strategies, are minimal. A recent study in India showed • Improve training of health care professionals to ensure that covering costs for both first- and second-line therapy appropriate treatment and other medical costs alleviates the financial burden • Improve resources and consider cost-effective innova- from epilepsy and is cost-effective across wealth quintiles tive health care delivery options. and in all Indian states (Megiddo and others 2016). WHO conducted a cost-effectiveness analysis of epilepsy treat- Patient-Related Factors ment in nine developing regions of the world (Chisholm • Improve knowledge about epilepsy to dispel myths and WHO-CHOICE 2005). Both studies found that and misconceptions about epilepsy, its causes, and its first-line medications, such as phenobarbital, represent a treatment highly cost-effective use of resources for health (see also • Develop interventions to address stigma chapter 12 in this volume [Levin and Chisholm 2015]). • Implement policy and legislation to ensure access to and Surgery has been shown to be cost-effective in appro- financial assistance for treatment. priately selected candidates in HICs, with health care costs declining significantly after successful surgery (Jette, Reid, and Wiebe 2014, Langfitt and others 2007). A summary of health economic analyses of epilepsy sur- DEMENTIA gery found that, in general, the costs per quality-adjusted Dementia poses a unique burden to those affected, their life year for epilepsy surgery are well within the “very families, and societies. Substantial projected increases of cost-effective” range recommended by the WHO (Jette patients with dementia in LMICs will pose additional and Wiebe 2015; Langfitt 1997). In the United States, economic and social burdens. Dementia is often erro- for example, the incremental cost-effectiveness ratio was neously considered an unavoidable part of aging or a US$27,200, considering direct and indirect costs, which condition for which nothing can be done; limited under- is well below the country’s gross domestic product per standing and the persistence of stigma and discrimina- capita of US$40,000. Unfortunately, economic evalua- tion limit help-seeking. Consequently, timely diagnosis tions of epilepsy surgery in children, older adults, and is the exception rather than the norm; most people are from LMICs are generally lacking. In addition, most not diagnosed and have limited access to adequate health economic analyses focus on temporal lobe surgery. or social care. Because pharmacotherapy and psycholog- ical and psychosocial interventions that can ameliorate Conclusions symptoms and lessen the impact on family members The dire consequences of poorly treated epilepsy include and caregivers are often unavailable, the treatment gap significant morbidity and mortality caused by seizures remains very large, particularly in countries where cul- and related injuries. The ongoing stigma associated tural and infrastructure barriers persist. with seizures remains a major challenge to clinical care in many regions, as well as the poor access to proper medications that can adequately treat this population. Definitions Ultimately, it is likely that the most effective target to Dementia is a neuropsychiatric syndrome character- address the treatment gap of epilepsy globally will be leg- ized by a combination of cognitive decline, progressive islative changes and anti-stigma interventions. Among behavioral and psychological symptoms (BPSD), and the required legislative efforts are those that advocate functional disability (WHO 2012). Dementia is usually better provision of benefits for functionally disabled per- chronic and progressive; its insidious onset is typically sons with epilepsy, especially in resource-poor countries characterized by objective deficits in one or more cog- where they are most needed. nitive domains, such as memory, orientation, language, Neurological Disorders 93 and executive function that are at the late stages accom- of those were in LMICs. This figure will nearly double panied by behavioral disturbances. Although age is the to 76 million in 2030 and to 145 million by 2050. The most significant risk factor, dementia is not a normal majority (71 percent) of new cases will occur in LMICs part of aging (Ganguli and others 2000; Kukull and oth- (figure 5.2) (Prince and others 2015; WHO 2015). The ers 2002; Launer and others 1999). The clinical onset of steepest projected increases in numbers of people with dementia is marked by the impact of cognitive decline dementia are expected in these settings because of rapid in everyday activities, and diagnosis is often made by demographic changes. A new dementia case is diagnosed physical and neurological examination with supporting every four seconds in the world, leading to 7.7 million evidence from informant interviews. new cases per year; nearly 50 percent of new cases occur Dementia is a syndrome that includes Alzheimer’s in Asia (WHO 2015). disease; vascular dementia; frontotemporal dementia; In community-based samples, the prevalence of Lewy body dementia; and reversible causes, for exam- dementia varies from 38 to 400 per 100,000 inhab- ple, hypercalcemia, thyroid hormone abnormalities, itants, with an increasing incidence over 55 years. vitamin B12 and folic acid deficiencies, HIV, sub- Frontotemporal dementia (9.7 percent), alcohol-related dural hematoma, and normal pressure hydrocephalus. dementia (9.4 percent), traumatic brain injury (3.8 Alzheimer’s disease accounts for 50–60 percent of all percent), and Huntington’s disease (3 percent) are more late-life dementias, and vascular dementia accounts frequently present in early-onset dementia (EOD) com- for up to 15–20 percent. Although brain pathological pared with late-onset dementia (Picard and others lesions differ across dementia subtypes, mixed forms 2011). Although dementia is more common in older age, of dementia are common, and vascular brain damage some people develop symptoms at a younger age com- often co-occurs. patible with EOD, a poorly understood and frequently underdiagnosed condition. Independent of the age at onset, most patients are Epidemiology and Burden of Dementia cared for at home by close relatives. Need for one-on- The most significant risk factor of dementia is increas- one care starts early, becomes increasingly intense, and ing age; the incidence doubles with every five-year may change significantly throughout the natural history increment after age 65 (WHO 2015). The graying of of the disease. Mood and behavioral changes, memory societies in all global regions is expected to increase the impairment for recent events, and spatiotemporal disori- number affected substantially. In 2015, approximately 47 entation, as well as problem-solving deficits that charac- million people had some form of dementia; 63 percent terize the early stage, may expose people with dementia Figure 5.2 Projected Growth in Number of People with Dementia in All Income Groups, 2010–50 120 Number of people with dementia (millions) 100 80 60 40 20 0 2000 2010 2020 2030 2040 2050 2060 High income Low and middle income Source: WHO 2012. 94 Mental, Neurological, and Substance Use Disorders and their families to stressful situations well before the in LMICs, where life expectancy is increasing, and clinical diagnosis is made. Later, mood and behavioral resources for the provision of health care for older disorders further increase the burden of the disease. adults are limited or unavailable. The later stages are characterized by diffuse involve- In HICs, the level of care needed is the single stron- ment with psychological and behavioral symptoms, gest predictor of institutionalization of older adults. In including repetitive behaviors, hallucinations, aggres- LMICs, institutionalization is less likely; people with sion, and wandering (Kales and others 2014). In contrast dementia tend to stay in their homes through the very to cognitive deficits, these symptoms are strongly related advanced stages of the disease, cared for by informal to institutionalization (Richardson and others 2013). caregivers, who are almost invariably close relatives and Caring for persons with dementia is associated with women. increasing physical and emotional stress. Studies show The direct costs include health service use, health that caregivers often have feelings of isolation, anxiety, care, and institutionalization; the indirect costs include and depression that reduce the quality of life and may those associated with cutting back on work to provide impact the quality of care they provide (Reitz, Brayne, care. Both pose significant financial burdens on individ- and Mayeux 2011). The cumulative distress of caregivers uals, families, and societies. constitutes a central component of the dementia burden The global economic cost in 2013 was US$604 (Donaldson and Burns 1999). billion, approximately 1 percent of the global gross domestic product (WHO 2015). The direct and indirect Global Burden of Dementia costs are proportionally higher in HICs. Moreover, the Dementia has become a significant economic bur- distribution of costs across medical, societal, and infor- den across the world (figure 5.3). The disease is the mal care varies strikingly across regions and health sys- leading cause of dependence in older adults in all tem organizations. Hospital inpatient costs contributed world regions; up to 50 percent of older adults who 70 percent of the direct costs for prevalent dementia, need care have dementia. According to the 2010 GBD mainly related to psychiatric care (Leibson and others report, the DALYs attributable to Alzheimer’s disease 2015). The indirect costs of informal care likely go far and other dementias doubled in the past 20 years, and beyond foregone income. There are potentially perni- dementia is estimated as the major driver of DALYs cious repercussions on families and social ties, caused in late life among all chronic diseases by virtue of its by caring for persons with dementia, particularly in strong association with mortality and dependence. settings where there are false beliefs about the causes The dementia-attributable DALYs may increase further and course. Figure 5.3 Distribution of the Total Societal Costs of Dementia Care, by World Bank Income Level 100 14.5 23.1 32.1 28.2 80 12.2 14.3 45.2 60 25.7 Percent 40 64.7 57.6 20 40.3 42.2 0 High-income Upper middle Lower middle Low-income countries income countries income countries countries Direct medical Direct social Informal care Source: WHO 2012. Neurological Disorders 95 Interventions before diagnosis. Loss of body weight may increase mor- Interventions need to address four key areas: bidity and mortality; yet, caregivers may be instructed • Timely diagnosis on simple practices and techniques to overcome prob- • Assessment and maintenance of physical health lems related to apathy and aversive feeding behaviors • Cognition, activity, and well-being; assessment and and may receive nutritional education to improve the treatment of BPSD caloric and nutritional content of meals. Finally, moni- • Support for caregivers. toring and effective treatment of vascular risk factors— including high blood pressure, hypercholesterolemia, smoking, obesity, and diabetes—should be encouraged Detection and Diagnosis of Dementia to improve secondary prevention of cerebrovascular The evidence does not support dementia screening events. Moreover, there is extensive and persuasive evi- in the general population at present. Screening tools dence from mechanistic and well-designed prospective in primary health services may be used for those who cohort studies that reducing the exposure to high blood report initial concerns about their cognitive function. pressure and hypertension in mid-life, and to diabetes Short versions of the Mini-Mental State Examination in mid- and late life, as well as the reduction in tobacco (Folstein, Folstein, and McHugh 1973) take as little as use and increase in educational level of populations, five minutes. However, unlike the Mini-Mental State can effectively reduce the dementia risk for populations Examination, which has been validated in several set- (Prince and others 2014). tings and languages, none of the short versions has been validated in LMICs, and their use is not recommended Pharmacological Interventions at present. Targets for pharmacological treatment include cognitive Diagnosis requires a clinical and informant interview impairment; behavioral symptoms, such as agitation and physical examination. Evidence from population- and aggression; and psychological symptoms, such as based studies, for example, the 10/66 culture-fair diag- depression, anxiety, and psychosis. There is a large body nostic algorithm (Prince and others 2003), suggests that of evidence for the efficacy of cholinesterase inhibitors diagnosis can be achieved using highly structured inter- (ChEIs), such as donepezil, rivastigmine, and galantam- views and examinations conducted by trained commu- ine, in the treatment of mild to moderate Alzheimer’s nity health workers. Adaptations for use in clinical practice disease (Institute for Quality and Efficiency in Healthcare are required, but the feasibility and cost-effectiveness of 2014). The use of each of these medications is associated laboratory tests used in HICs to exclude treatable forms with modest and short-term comparable improvements of dementia may limit their use in LMICs. Evidence from in cognitive function, global clinical state, and activities HICs indicates that the good practice of disclosure of the of daily living. However, the evidence base for ChEIs in dementia diagnosis allows better planning and may limit LMICs is limited. Moreover, the efficacy of this class of distress; evidence from LMICs is lacking. drugs in severe dementia is unclear, although behavioral Appropriate adaptation to local culture, language, symptom improvement was identified for galantamine and beliefs should shape the design of programs and (Institute for Quality and Efficiency in Healthcare 2014). activities planned and implemented, and involve stake- A fourth drug for the treatment of cognitive impair- holders, policy makers, the media, and local health care ment, memantine, has a different mode of action and services. Health and social services should be enhanced is well tolerated, but evidence for its efficacy is limited to meet the projected increase in services. to people with moderate to severe dementia. ChEIs and memantine are less efficacious in vascular dementia than Physical and Care Needs Assessment other forms. Their efficacy in the treatment of behavioral Information on care arrangements and resources disturbances is not established; manufacturer-sponsored should be considered along with the evaluation of licensing trials and post hoc analyses indicate small BPSD and the severity. A careful physical assessment is improvements. very important to monitor hearing and visual impair- Use of haloperidol and atypical antipsychotic med- ment, pain, constipation, urinary tract infections, and ications for the treatment of agitation and behavioral bedsores that may explain exacerbation of psycholog- symptoms with BPSD indicate small treatment effects, ical symptoms. Whether physical assessment improves most evident for aggression, although these must be dementia prognosis, particularly the course of cognitive weighed against the associated mortality risk (Kales and impairment, remains largely unknown. Nutritional sta- others 2012). Atypical antipsychotic drugs have been tus should be carefully monitored during the course of widely prescribed for psychosis in dementia, but a meta- the disease. Weight loss is common and may start even analysis of their efficacy indicated that only aripiprazole 96 Mental, Neurological, and Substance Use Disorders and risperidone had a statistically and clinically signifi- behavior disturbance and mood in the care recipient; cant effect on psychiatric symptoms (Tan and others and institutionalization. 2015). An important caveat to the use of these medi- Most caregiver-focused interventions reduce strain cations in dementia is the associated increased risk of and depression, with cognitive behavioral therapy hav- death and cerebrovascular adverse events. The literature ing the largest impact on depression (Aboulafia-Brakha of antipsychotic treatment in older people with demen- and others 2014; Martín-Carrasco and others 2009; tia reveals that although improvement in behavioral Selwood and others 2007; Van Mierlo and others 2012). disturbance was minimal after 6–12 weeks, there was Caregiver training models have been developed for a significant increase in absolute mortality risk of dementia care, including the Maximizing Independence approximately 1 percent (Banerjee, Filippi, and Allen at Home project (Tanner and others 2015). Psycho- Hauser 2009). As the literature suggests that prescrib- educational interventions required the active participa- ing antipsychotics in dementia continues beyond 6–12 tion of the caregiver to be effective. Caregiver support weeks, the harm of continued antipsychotic treatment increased well-being but no other outcomes. in dementia is likely to be substantial. Therefore, many For respite care, methodologically flawed RCTs recommend nonpharmacological treatments, such as showed no benefit on any outcome (Grant and others psychological and training interventions, to reduce 2003; Maayan, Soares-Weiser, and Lee 2014). However, BPSD rather than antipsychotic management (Deudon nonrandomized studies suggest that respite care sig- and others 2009). nificantly reduces caregiver strain and psychological A meta-analysis of the efficacy of antidepressants in morbidity (Ornstein and others 2014). Interventions people with dementia was inconclusive (Leong 2014). targeting the caregiver may also have small but signifi- Antidepressants have been proposed for the treatment cant beneficial effects on the behavior of the person of BPSD with encouraging results (Henry, Williamson, with dementia. A systematic review of 10 RCTs indicated and Tampi 2011). a 40 percent reduction in the pooled odds of institution- alization; the effective interventions were structured, Nonpharmacological Interventions intensive, and multicomponent, offering a choice of A well-conducted RCT of cognitive stimulation (reality services and supports (Tam-Tham and others 2013). orientation, games, and discussions based on infor- Two small trials of a brief caregiver education and train- mation processing rather than knowledge) conducted ing intervention, one from India and one from Russia, in the United Kingdom as a group intervention, and indicated much larger treatment effects on caregiver a small pilot trial from Brazil, suggest that cognitive psychological morbidity and strain than typically seen benefits from this intervention are similar to those for such interventions in HICs (Gavrilova and others for ChEIs (Aguirre and others 2013). More specific 2009; Dias and others 2008). cognitive training produced no benefits. Cognitive rehabilitation, an individualized therapy designed to Interventions to Optimize Health Care Delivery enhance residual cognitive skills and the ability to Interventions to Increase Demand for Services. Raising cope with deficits, showed promise in uncontrolled awareness among the public, caregivers, and health case series in HICs. A meta-analysis of four trials of workers can lead to increased demands for services. reminiscence therapy (the discussion of past activities, Intergenerational solidarity can be promoted through events, and experiences) provides evidence for short- awareness-raising among children and young adults. term improvement in cognition, mood, and caregiver In many LMICs, many people with dementia live in mul- strain, but the quality of these trials was poor (Bahar- tigenerational households with young children, who are Fuchs, Clare, and Woods 2013; Woods and others 2005; the most frequent caregivers and the most likely to ini- Woods and others 2012). tiate help-seeking. The provision of disability pensions and caregiver benefits in LMICs is likely to increase Interventions for Caregivers requests for diagnostic assessment. Importantly, how- A large literature attests to the benefits of caregiver ever, efforts to increase awareness must be accompanied interventions. These include psycho-educational by health system and service reforms, so that help- interventions, often including caregiver training; seeking is met with a supply of better prepared, more psychological therapies, such as cognitive behav- responsive services. ioral therapy and counseling; caregiver support; and respite care. Many interventions combine several of Interventions to Improve the Capacity of Health Care these elements. The outcomes studied include care- Teams. Primary health care services in LMICs often fail giver strain, depression, and subjective well-being; older people because the services are clinic-based, often Neurological Disorders 97 focused on simple curative interventions, and face high that the cost per quality-adjusted life year gained from workloads. Given the frailty of many older people with early screening ranged from US$24,150 to US$35,661, dementia, there is a need for outreach to assess and man- depending on the age group. The probability of screen- age patients in their own homes. Dementia care should ing being cost-effective was highest in the group over age be an essential component of any chronic disease care 75 years in a wide range of willingness to pay (WTP) (Yu strategy. Training of nonspecialist health professionals and others 2015). The most cost-effective benefit of dis- should focus on case-finding and conveying the diagno- ease modifying therapies has been seen in moderate to sis to patients and caregivers together with information, severe dementia (Plosker and Lyseng-Williamson 2005). needs assessment, and training and support. Training can be service-based, as well as through changes to Pharmacotherapy medical and nursing schools, public health, and rural Available pharmacoeconomic data from Europe and health curricula. Medical and community care services the United States support the use of memantine as a should be planned and coordinated to respond to the cost-effective treatment. Two cost-effectiveness analy- increasing need for support as the disease progresses. ses of memantine in moderate-to-severe Alzheimer’s disease have been conducted in Finland and the United Community-Based Programs to Deliver Effective Kingdom; patient progression was simulated through Treatments. Programs to support caregivers can be health states related to dependency, residential setting, delivered individually or in groups by community and cognitive function (Francois and others 2004; Jones health workers or experienced caregivers. Strain, possi- and others 2004). Memantine reduced total societal bly associated with BPSD, should trigger more intensive costs by US$1,090 per patient per month, compared interventions that include psychological assessment and with no pharmacological treatment, over 28 weeks in a depression treatment for the caregiver, respite care, and resource utilization and cost analysis conducted along- caregiver education and training. Such interventions side a pivotal trial in patients in the United States with could be incorporated into horizontally constructed, moderate-to-severe Alzheimer’s disease (Wimo and oth- community-based programs that address the generic ers 2003). Results were primarily driven by reductions needs of frail, dependent, older people and their care- in total caregiver costs, which included the opportunity givers, whether these needs arise from cognitive, mental, cost of time spent in caregiving tasks, and in direct or physical disorders. Recent evidence has demonstrated nonmedical costs, which included the cost of care in a the effectiveness of delivery of Internet–based caregiver nursing home or similar institution. interventions (Czaja and Rubert 2002; Marziali and An analysis in Canada found that treatment with Garcia 2011). rivastigmine yielded savings in the direct cost of caring for patients with Alzheimer’s disease that exceed the cost of the drug after two years of treatment (Hauber and Dementia: Cost-Effectiveness of Interventions others 2000). In a 20-year Markov cohort model of dis- The estimated worldwide societal cost of dementia ease modifying treatment in Alzheimer’s disease based exceeded US$818 billion dollars in 2015 (Prince and on a Swedish population, the sensitivity analysis implied others 2015). Direct costs include health service use no cost savings with disease modifying therapy, but most and institutionalization; the indirect costs include those options indicated cost effectiveness verses the chosen associated with inability to work and caregiver care. Both WTP (Skoldunger and others 2013). In another study kinds of costs impose significant financial burdens on evaluating treatment with cholinesterase inhibitors or individuals, families, and societies. Informal care costs memantine for those with mild to moderate vascular are proportionally highest in LMICs, while the direct dementia, donepezil 10 mg orally daily was found to costs for social care account for over half the costs in be the most cost-effective treatment (Wong and others HICs (Prince and others 2015). Several studies, most in 2009). HICs, have evaluated the cost effectiveness of interven- tions in dementia. Particular challenges in such studies Other Therapies are the heterogeneity in etiology of dementia and the In terms of nonpharmacologic therapies, cognitive stim- capture of cost-effectiveness in patients with milder ulation therapy has been shown to be cost-effective for forms of cognitive impairment. people with mild-to moderate dementia when delivered biweekly over 7 weeks though was found to have modest Screening effects when continued for longer when added to admin- A study in the Republic of Korea, where there is a nation- istration of acetylcholinesterase inhibitors (D’Amico and wide early detection program for dementia, showed others 2015). An exercise intervention was found to have 98 Mental, Neurological, and Substance Use Disorders the potential to be cost-effective when considering behav- Headache disorders are the most frequent cause of ioral and psychological symptoms but did not appear consultation in primary care and neurology practice; it cost-effective when considering quality-adjusted life prompts many visits to internists; ear, nose, and throat year gains. The START (STrAtegies for RelaTives) study, specialists; ophthalmologists; dentists; psychologists; and a randomised controlled trial to determine the clinical proponents of a wide variety of complementary and alter- effectiveness and cost-effectiveness of a manual-based native medical practices (WHO 2011). Headache is a com- coping strategy program in promoting the mental health mon presenting symptom in emergency departments. The of carers of people with dementia, found the interven- consequences of recurring migraine include pain, disabil- tion to be cost-effective with respect to caregiver and ity, diminished productivity, financial losses, and impaired patient outcomes, and National Institute for Health quality of life. Therefore, although headache rarely signals and Care Excellence (NICE) thresholds (Livingston and serious underlying illness, its causal association with per- other 2014). In a health economic analysis of resource sonal burdens of pain, disability, and diminished quality costs and costs of formal care on a psychosocial inter- of life makes it a major contributor to ill health. vention for family caregivers of persons with dementia, those in the intervention group reported higher quality Definitions of life while their spouse was living at home (Dahlrup and others 2014). Migraine Migraine is a disorder commonly beginning in puberty and often lasting throughout life. Episodic attacks have Conclusions a frequency of once or twice a month on average, but Research for early diagnosis is important in view of the this may vary widely, subject to lifestyle and environ- future availability of treatments that are likely to be more mental factors. In women, prevalence is higher because efficacious in the early stages of the disease, when diag- of a hormonally-driven association with menstrua- nosis is more difficult. At present, there are no disease- tion. Headache, nausea, and photophobia are the most modifying pharmacological treatments for dementia, characteristic attack features. In some attacks, about 10 and medications to treat symptoms appear to have lim- percent overall, and in only one-third of people with ited efficacy (Birks 2006; McShane, Areosa Sastre, and migraine, headache is preceded by aura symptoms, most Minakaran 2006). The ambitious goal to identify a cure commonly visual. The headache itself, lasting for hours for Alzheimer’s disease by 2025, which was announced to two to three days, is typically moderate or severe and by world political leaders in 2013 during the G8 meeting unilateral, pulsating, and aggravated by routine physical in London, underscores the recognition of dementia as activity (International Headache Society 2013). Chronic a global health threat and priority. However, the quest migraine, with headache attacks on 15 or more days per for a cure should not drain resources from research on month and/or loss of episodicity, is a particularly dis- modifiable risk factors, which remains crucial for pre- abling form (Natoli and others 2010). vention, to potentially delay the symptomatic onset or slow the disease progression. The first WHO Ministerial Tension-Type Headache Conference on Global Action Against Dementia was TTH is a highly variable disorder, commonly beginning held in March 2015 to foster awareness of the public in the teenage years and reaching peak levels for people health and economic challenges posed by dementia and in their 30s. It lacks the specific features and associated improve the understanding of the roles and responsibil- symptoms of migraine, with headache usually mild or ities of Member States and stakeholders; it led to a Call moderate, generalized, and described as pressure or for Action supported by conference participants. Indeed, tightness (International Headache Society 2013). a broad public health approach to address the complex challenges of dementia is extremely important. Medication-Overuse Headache MOH is earning recognition as a disorder of major public health importance for three reasons: it is an HEADACHE DISORDERS attribute of migraine or (less often) TTH; it is highly The three headache disorders of particular public health disabling at individual levels; and it is iatrogenic and importance are migraine, TTH, and MOH. Collectively, avoidable. MOH affects between 1 and 2 percent of the these three are the third most common cause of disabil- general population (Westergaard and others 2014), up ity in populations throughout the world (Murray and to 67 percent of the chronic headache population, and others 2012; Steiner and others 2015; Stovner and others 30–50 percent of patients seen in specialized headache 2007; Vos and others 2012). centers (Evers, Jensen, and European Federation of Neurological Disorders 99 Neurological Societies 2011). The cause is chronic exces- Self-Management sive use of medications taken initially to treat episodic Stress is a common predisposing factor for migraine. headache (Diener and Limmroth 2004). The overuse Improving the ability to cope is an alternative treat- of all such medications is associated with this problem, ment approach, but the role of psychological therapies although the mechanism through which it develops in migraine management is unclear. Most research has undoubtedly varies among drug classes (Steiner and focused on high-end intensive treatment of individual others 2007). cases of disabling and refractory headache, which has limited relevance to public health. Yet there is potential for low-cost delivery of group behavioral training, and Epidemiology and Burden of Disease even some very limited evidence of benefit (Mérelle and others 2008). This approach could be further explored Estimating the global burden of headache disorders is in LMICs. a challenging task, given data paucity for many LMICs, Obesity is a risk factor for migraine, especially for variations in methodologies in epidemiological stud- frequent migraine (Evans and others 2012). Regular ies, and variation of cultural attitudes related to the exercise and keeping fit can be beneficial. A study among reporting of complaints. Much of the world’s popula- obese adolescents with migraine found a significant tion lives in countries where headache prevalence and improvement in headache in those who participated in a burden are incompletely known (Stovner and others 12-month weight-loss program (Evans and others 2012). 2007). Regardless, estimations have been done and show that the global one-year prevalence of migraine Pharmacological Interventions constitutes 14.7 percent and TTH 20.8 percent of Guidelines recommend a stepped-care approach com- adults ages 18–65 (Murray and others 2012). The mencing with acute treatment using simple anal- prevalence of all types of headache occurring on 15 gesics (aspirin or one of several other nonsteroidal or more days per month (including chronic migraine, anti-inflammatory drugs) (Steiner and others 2007). chronic TTH, and MOH) is 3 percent (Stovner and Good evidence demonstrates the efficacy and tolerability others 2007). Although the prevalence of migraine is of aspirin (Kirthi, Derry and Moore 2013), ibupro- markedly lower in Asia (Stovner and others 2007) and fen (Rabbie, Derry and Moore 2013), and diclofenac was thought to be so in Africa, a study in Zambia has potassium (Derry, Rabbie, and Moore 2013). The most indicated a high one-year prevalence (22.9 percent), desirable outcome of acute treatment is complete relief coupled with very high prevalences of headache on from pain within two hours, without recurrence or need 15 or more days a month (11.5 percent) and proba- for further medication and without adverse events. This ble MOH (7.1 percent), with considerable economic outcome is not commonly experienced with simple anal- impact (Mbewe and others 2015). gesics alone. The more easily achievable outcome referred to as sustained headache relief (SHR) is defined as Interventions reduction of pain to no worse than mild within two Worldwide, at least 50 percent of headaches are self- hours of treatment, also without recurrence or need treated, even in high-income countries (HICs) (WHO for further medication. Mild pain is assumed not 2011). Professional health care, when needed, should to be associated with disability, and SHR implies be provided in primary care settings for the majority full functional recovery when functional impairment of cases (WHO 2011), and guidelines for the man- was present initially. Aspirin alone provides SHR in agement of headache disorders in these settings are an estimated 39 percent of users (Kirthi, Derry and available (Steiner and others 2007). History and exami- Moore 2013); this is a modest effect in the sense that it nation should take due note of warning features that leaves 61 percent without this benefit but at the same might suggest an underlying condition (Steiner and time is among the most cost-efficient interventions to others 2007). improve public health (Linde, Steiner, and Chisholm Many instruments, including the HALT ques- 2015). Aspirin has the advantages of being universally tionnaire, are available to assess the burden of head- available and on the WHO essential medicines list ache symptoms on individual patients. (Steiner and (WHO 2013). Ibuprofen provides SHR in a somewhat Martelletti 2007). Realistic goals of management include higher estimated proportion of users (45 percent) understanding that primary headaches cannot be cured (Rabbie, Derry, and Moore 2013), at variable but but can be managed effectively. We focus our further not always higher cost. Diclofenac is considerably treatment discussions on migraine. more costly, without significantly greater efficacy 100 Mental, Neurological, and Substance Use Disorders (Derry, Rabbie, and Moore 2013). It is argued that Steiner, and Chisholm 2015). In an American Academy the anti-inflammatory effect is important in acute of Neurology review, divalproex sodium, sodium val- migraine treatment, and paracetamol is therefore proate, topiramate, metoprolol, propranolol, and timo- rather less effective than aspirin (at the same cost) or lol were found to be effective for migraine prevention other nonsteroidal anti-inflammatory drugs (Derry (Silberstein and others 2012). In terms of cost, propra- and Moore 2013; Steiner and others 2007). nolol and amitriptyline are similar and very low, and Antiemetics should also be used in acute treat- topiramate is much higher; amitriptyline might be the ment, and should not be restricted to patients who are choice of prophylactic drug when resource conservation vomiting or likely to vomit. Nausea is one of the most is the key consideration (Linde, Steiner, and Chisholm aversive and disabling symptoms of a migraine attack 2015). However, the mode of action of these medica- and should be treated appropriately (Silberstein and tions in migraine is unknown, and failure of response others 2012). Gastric stasis is a feature of migraine; to one does not predict the failure of others (Steiner and prokinetic antiemetics, such as domperidone or meto- others 2007), which might be tried when amitriptyline clopramide, enhance gastric emptying and promote is ineffective and resources permit. the efficacy of oral analgesics in migraine. The usual second step in management is still acute Alternative Therapies treatment, with the substitution or addition of specific Acupuncture and physical therapies, such as spinal anti-migraine therapy (Steiner and others 2007). manipulation, requiring direct one-to-one therapist- Ergotamine tartrate remains in use in many coun- patient interaction, are highly resource intensive, and tries (WHO 2011), but it is poorly bioavailable, is not have questionable efficacy (Bronfort and others 2004; highly effective, and has potential side effects. Of the Linde and others 2009) to justify their recommendation. triptan class of agents–which are specific anti-migraine Even the limited benefits seen in clinical trials may not medications–seven are available in many countries. They be replicated in the real world, where therapists operate differ somewhat in their pharmacokinetics, and they under time constraints. are not identical in efficacy; however, the differences between them are small when set against the up to ten- Public Education Programs fold price differences between sumatriptan (available in Public education programs can help to improve migraine generic versions) and the other six. Sumatriptan is avail- outcomes. Lifestyle factors may predispose people to or able in four formulations (oral, intranasal, rectal, and aggravate migraine. Although the evidence is poor that subcutaneous). Sumatriptan 50 mg orally provides SHR modifying lifestyle is an effective way of controlling in an estimated 35 percent of users (Derry, Derry, and migraine, avoidance of trigger factors is a logical strata- Moore 2012), much the same as aspirin; however, it has gem (Steiner and others 2007). a different mode of action, and responses to each drug Public education about the increasing risk of are independent. When sumatriptan is used on its own, migraine with obesity (Bronfort and others 2004) may its cost-effectiveness is at least two orders of magnitude achieve some benefits, because, unlike many other ill- lower than that of aspirin (Linde, Steiner, and Chisholm health consequences of obesity, headache is experienced 2015); it is usually reserved as a second-line treatment in the present. Public education also appears to offer the for those who fail to respond to first-line treatments most effective means of controlling a potential epidemic (Steiner and others 2007). In adults and children, regular of MOH as a consequence of mistreated migraine. use of acute medications at high frequency (more than Recent evidence from the Global Campaign against two days per week) risks the development of MOH. Headache (Mbewe and others 2015) suggests this may Prophylactic medications are used in step three to be a particular problem in LMICs where medications are reduce the number of attacks occurring when acute relatively more affordable and available than health care. therapy is inadequate (Steiner and others 2007). There The initial effectiveness of simple analgesics encour- is adequate or good evidence of efficacy and tolerability ages their further use, which is not problematic at low for propranolol (Linde and others 2013b), amitriptyline frequency. With increasing frequency comes greater (Dodick and others 2009), valproate (as sodium val- reliance and increasing risk of MOH. Once MOH is proate or valproic acid) (Linde and others 2013b), and established, medication overuse is likely to escalate. topiramate (Diener and others 2004; Linde and others The incremental health benefits obtained in LMICs 2013a). To assess outcome as migraine attacks averted from adding educational programs to the use of over- requires comparison with an untreated base line, which the-counter and prescription medications appear to is available for propranolol (28 percent) (Linde, Steiner, be achievable at acceptable incremental costs (Linde, and Chisholm 2015), amitriptyline (44 percent) (Linde, Steiner, and Chisholm 2015). Pharmacists can be a key Neurological Disorders 101 source of information to the public about headache and Chisholm 2015). Furthermore, such training might disorders, treatments, and the dangers of medication reduce waste, through reductions in the high rates of overuse, but only if this role is explicitly recognized unnecessary investigations to support diagnosis (WHO in their reimbursement, and only if their advice 2011). is sought. Further, the cost-effectiveness of treat- ments may increase with public education programs to improve adherence to treatments (Linde, Steiner, and Cost-Effectiveness of Interventions Chisholm 2015). There is a lack of nationally conducted cost-effectiveness studies to inform resource allocation decisions for head- Interventions to Optimize Health Care Delivery ache disorders in LMICs. However, a recent cost- In a global survey, one-third of responding countries effectiveness modeling analysis of migraine treatment recommended improved organization and delivery of was carried out for four countries–China (an upper- health care for headache so that care would be effi- middle-income country), India (a lower-middle-income cient and equitable (WHO 2011). The organization of country), Russia (an HIC), and Zambia (a lower- services to achieve this goal is clearly a challenge, and no middle-income country). The analysis concluded that single solution may be appropriate in all settings. Most acute treatment with aspirin generated a year of healthy patients do not require specialist expertise or special life for less than US$100 (Linde, Steiner, and Chisholm investigations (Steiner and others 2007), and the three- 2015), making it among the most efficient interventions tier service model developed by the Global Campaign to improve population health. Cost-effectiveness analy- against Headache for Europe (Steiner and others 2011) sis was not carried out for paracetamol specifically, is highly adaptable. This model had been used as part because the only evidence of SHR came from 42 highly of demonstration projects to structure headache ser- atypical patients in the United States (Linde, Steiner, vices in China (Yu and others 2014), and in Sverdlovsk and Chisholm 2015). When sumatriptan is used on its Oblast in the Russian Federation (Lebedeva and others own for acute management of migraine, its cost- 2013). Using the model, about 90 percent of patients are effectiveness is at least two orders of magnitude less managed in first-level care, usually but not necessarily favorable than that of aspirin, which indicates why by physicians; 1 percent require specialist care that is sumatriptan is reserved as a second-line treatment for necessarily hospital-based. The intermediate 9 percent those who fail to respond to first-line treatments (Steiner do not require specialist care, but may have diagnostic and others 2007). or management difficulties that would benefit from Prophylactic medications are less cost-effective second-level care. Provision of this level of care depends than acute therapy with simple analgesics, but con- on resources and local health service organizations. Each siderably more cost-effective than acute therapy with level must maintain a gatekeeper role to higher levels to the combination of analgesics and triptans (when make the model work. needed), but this may be true only if prophylactics Countries that have invested in headache services are reserved for those with three or more attacks per have, paradoxically, generally done so by setting up month (Linde, Steiner, and Chisholm 2015). The specialist headache clinics. Worldwide, the proportion addition of educational programs (posters and leaf- of headache patients seen by specialists is 10 percent lets in pharmacies) for the use of over-the-counter (WHO 2011), indicating considerable scope for resource and prescription medications appears to increase reallocation for the benefit of more patients if the levels population health gain at an acceptable incremental below were better utilized. Pharmacists need to be for- cost, as does training providers (Linde, Steiner, and mally integrated into health care systems. Chisholm 2015). Training Health Care Providers. The ability of first- level services to deliver effective care depends on the Conclusions providers—physicians, clinical officers, or nurses— It is clear that investment in structured headache ser- having the basic knowledge required. Evidence clearly vices, with their basis in primary care and supported indicates deficiencies, and better professional educa- by educational initiatives aimed at professionals and tion ranked far above all other proposals for change in the public, is the way forward for most countries. WHO’s global survey (WHO 2011). Training first-level Such services require resource reallocation which is doctors in the management of migraine is likely to easily justified economically. Importantly, services for improve outcomes, as well as to increase the cost- migraine would simultaneously provide for the other effectiveness of prescription medications (Linde, Steiner, common and disabling headache disorders. The gains 102 Mental, Neurological, and Substance Use Disorders in population health achievable through effective head- REFERENCES ache management are substantial and independent of Aboulafia-Brakha, T., D. Suchecki, F. 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First, In 2012, by various estimates, 165 million to 315 million we describe patterns of dependence and the disease people ages 15–64 years worldwide used illicit drugs, includ- burden (mortality, morbidity, and societal economic ing those in the following categories (UNODC 2013):1 costs) attributable to dependence, by global region. Second, we summarize evidence on the effectiveness of • Cannabis products. Marijuana, hashish, and bhang interventions to reduce illicit drug dependence and the are the most widely used drugs, with an estimated harm caused by such dependence. Finally, we consider 181 million users (129 million to 230 million) con- the extent to which research on illicit drug dependence stituting 3.9 percent of the global population ages in high-income countries (HICs) is relevant to disease 15–64 years. control priorities in LMICs. • Amphetamine-type stimulants (ATSs). The next In undertaking the reviews for this chapter, we relied most widely used illicit drugs are stimulants such on previous systematic reviews of the epidemiology as cocaine; methamphetamine; drugs with stimu- of drug use, dependence, and health consequences lant and hallucinogenic properties, such as MDMA (Degenhardt and Hall 2012), many of which were con- (3,4-methylenedioxy-N-methylamphetamine), or ducted for the Global Burden of Disease (GBD) 2010 ecstasy; and novel psychoactive substances,2 with an study (Degenhardt, Whiteford, and others 2013). Our estimated 34 million users worldwide (14 million review of interventions drew heavily on our previous to 53 million), including 17 million cocaine users work reviewing effective interventions for illicit drug use (14 million to 21 million), and 20 million MDMA and dependence (Strang and others 2012). We updated users (10 million to 29 million). these with a review-of-reviews approach, whereby we • Illicit opioids. An estimated 17 million persons use conducted a systematic review of reviews of interven- heroin or opium; 32 million use any illicit opioid, tions to address illicit drug use and dependence. including diverted pharmaceutical opioids, such as methadone or morphine (28 million to 36 million). Definition of Illicit Drug Dependence The health risks of illicit drug use increase with the fre- Scope of the Chapter quency and quantity of use and route of administration. This chapter is concerned with cannabis, amphet- The International Classification of Diseases (ICD) amine, and opioid dependence. The chapter identifies defines harmful use if there is evidence that substance disease control priorities for illicit drug dependence use is causing physical or psychological harm; it defines Corresponding author: Louisa Degenhardt, Ph.D., National Drug and Alcohol Research Centre, UNSW Australia, l.degenhardt@unsw.edu.au. 109 drug dependence if three or more indicators of depen- • Family factors: poor quality of parent-child interac- dence are present for at least one month within the past tion and relationships, parental conflict, and parental year (WHO 1993). and sibling drug use The Diagnostic and Statistical Manual of Mental • Individual factors: male gender; having an external- Disorders, 4th edition (DSM-4) used a similar classifica- izing disorder, such as attention-deficit hyperactivity tion for substance abuse and substance dependence (APA disorder or conduct disorders in early childhood; 2000). However, the fifth edition (DSM-5) defines a sensation- and novelty-seeking personality traits; and substance use disorder if two of 11 criteria grouped under low education levels impaired control, social impairment, risky use, and • Peer group factors: association with antisocial or pharmacological dependence are present; it categorizes drug-dependent peers, which is one of the strongest the severity along a continuum of mild, moderate, and risk factors for illicit drug dependence in adolescence severe disorders, based on the number of criteria present and which operates independently of social, contex- (APA 2013). tual, family, and individual factors. NATURAL HISTORY OF DEPENDENCE Consequences Onset of illicit drug use typically occurs in the mid- to Mortality late teens and peaks in the early to late 20s; few users Mortality rates for heavy users of opioids, amphet- continue beyond age 40 years (Degenhardt, Whiteford, amines, and cocaine are 3–14 times higher across the and others 2013). The percentage of illicit drug users lifespan than for the general population (Degenhardt, who transit from use to dependence ranges from Bucello, Mathers, and others 2011; Stenbacka, Leifman, 9 percent for cannabis to 20–25 percent for users of and Romelsjo 2010). In 2011, an estimated 211,000 psychostimulants and heroin (Lopez-Quintero and people died from drug-related causes, mostly younger others 2011). Cannabis use accounts for 80 percent users whose deaths were primarily preventable of illicit drug use worldwide; the dependence risk (UNODC 2013). is lower, and the morbidity attributable to its use is Based on the type of drug dependence, studies have smaller, than for other drugs (Degenhardt, Whiteford, found the following risk correlations: and others 2013). The lag time from illicit drug use to dependence • Heroin. Long-term heroin users have a substantially is shorter than that observed for substances such as increased risk of premature death from drug over- nicotine and alcohol (Behrendt and others 2009). dose, violence, suicide, and alcohol-related causes Dependence can occur within 1.5–2 years of cocaine (Degenhardt, Charlson, and others 2014). and opioid use and within three years of cannabis use • Amphetamines. Amphetamine-related deaths typi- (Florez-Salamanca and others 2013; Wu and others cally are associated with cardiac failure and cerebral 2011). vascular accidents (Darke and others 2008). The 2010 rates of cannabis and opioid dependence • Cocaine. Cocaine dependence is associated with ele- were higher in HICs than LMICs; cocaine use and depen- vated risks of intentional and accidental injuries dence rates were highest in North America and tropi- (Blow and others 2011). Cocaine-related deaths are cal and southern Latin America (Degenhardt, Bucello, usually related to cardiovascular complications, brain Calabria, and others 2011). Amphetamine dependence hemorrhage, stroke, and kidney failure (Restrepo and rates, however, appear to be highest in Southeast Asia others 2009). and Australasia (Degenhardt, Baxter, and others 2014). • Cannabis. Cannabis dependence is associated with significant disability burden, including the precipi- tation of psychosis in vulnerable people (Bloomfield Risk Factors and others 2013). Risk factors often coexist and are similar across the dif- ferent categories of illicit drugs, as well as across global HIV and Hepatitis Infection regions (Degenhardt and others 2010): In 2010, injecting drug use accounted for almost two million years of life lost (YLLs) globally as a risk • Social and contextual factors: low socioeconomic sta- from HIV infection (Degenhardt, Whiteford, and others tus, early substance-use onset, and social norms that 2013). Injecting drug use has been a major driver of HIV are tolerant of alcohol and other drug use epidemics in LMICs (Mathers and others 2010). 110 Mental, Neurological, and Substance Use Disorders Hepatitis B and C infection is highly prevalent globally Consumption Trends among people who inject drugs (Nelson and others 2011). Despite reported increases in the global number of illicit Chronic infection occurs in 75 percent of infections, and substance users, other indicators such as area under drug 3–11 percent of chronic hepatitis C virus (HCV) carriers cultivation, production, manufacture, and seizures sug- develop liver cirrhosis within 20 years. The risk of HIV gest that consumption (about 167 million to 315 million and hepatitis C infection is elevated among non-injecting users) has remained relatively stable since 2010 (UNODC drug users; psychostimulants such as crack cocaine and 2013). The illicit market for ATSs appears to be growing, amphetamine disinhibit users and facilitate riskier sexual with global increases in seizures, particularly in Africa and activity and increase the risk of HIV infection (Volkow Mexico (see UNODC 2013). Cocaine markets appear to and others 2007). Among men who have sex with men, be shifting from the United States and Western Europe amphetamines (specifically, crystal methamphetamine) to Asia. Heroin availability, use, and overdose also appear may be used to enhance sexual encounters, increasing the to be increasing in Asia and East and West Africa and the risk of HIV infection from unprotected anal intercourse United States. Afghanistan saw large increases in heroin (Rajasingham and others 2012). availability and an increased net cultivation of 36 percent from 2012 to 2013, and a 140 percent increase in estimated Criminal Activity regular users from 2005 to 2009 (UNODC 2009). The relatively few adults who become dependent on Of particular concern is the large increase in depen- heroin have a disproportionate criminal impact on dence on pharmaceutical opioids, such as oxycodone, their communities. The average heroin user engages in methadone, hydrocodone, and fentanyl. In the United criminal behavior 40–60 percent of the time that he or States, the annual incidence of pharmaceutical opioid she is not incarcerated or in treatment (Ball, Shaffer, and abuse rose by almost 300 percent from 1990 (628,000 Nurco 1983); the most common offenses include drug initiates) to 2001 (2.4 million) (U.S. Department of dealing and property crimes (Degenhardt, Larney, and Health and Human Services 2012); treatment admis- others 2013). sions and death rates due to overdose increased from 1999 to 2008 (CDC 2012). Similarly large increases in Economic Losses pharmaceutical opioid prescriptions and abuse have The production, distribution, and consumption of illicit been reported in Australia, Estonia, Finland, and New drugs result in significant economic costs affecting con- Zealand (UNODC 2013). sumers, families, industries, societies, and governments. For example, there is a strong correlation between unem- Burden of Disease Trends ployment and drug use in HICs and LMICs. Illicit drug The GBD 2010 study found that disability-adjusted life use limits the affected individuals’ chances of entering or years (DALYs) from drug use disorders rose 52 percent, remaining in the workforce and is linked to low produc- from 13.1 million in 1990 to 20.0 million in 2010 tivity and accidents. Drug-taking employees in the United (Degenhardt, Whiteford, and others 2013). Population States are absent three times more often, are three to four growth accounted for 28 percent and increased prevalence times more likely to be involved in a workplace accident, for 22 percent of the increase in this period. The overall and file approximately five times more workers’ compen- opioid dependence burden increased by 74 percent from sation claims than non-drug-taking employees (UNDCP 1990 to 2010, amounting to almost four million addi- 1998). There are opportunity costs of the expenditures tional DALYs in 2010 (Degenhardt, Charlson, and others used to treat illicit drug dependence, prevent crime, 2014). Much of the drug-related increase in DALYs can be enforce laws, and process drug-dependent offenders in attributed to population growth; one exception is opioid the judicial system. For example, the economic cost of dependence, in which 56 percent of the total increase in drug abuse was estimated at 2 percent of gross domestic DALYs was attributable to increased prevalence. product in Australia (Collins and Lapsley 2007). INTERVENTIONS AND POLICIES: Trends EFFECTIVENESS AND COVERAGE Global trends are difficult to estimate because drug use Research on the effectiveness and cost-effectiveness of is routinely tracked only in a minority of HICs; assess- policies and interventions for control of illicit drug use ments of trends in other countries often rely on indirect has varied in quantity and quality and largely comes indicators, such as law enforcement data on drug sei- from a few HICs, although recent research has assessed zures, demand for treatment, and overdose deaths. these interventions in LMICs. Illicit Drug Dependence 111 Population Platform Interventions (Strang and others 2012). Although there is limited evi- Interventions to reduce the availability of illicit drugs dence on the effectiveness of these expensive strategies and discourage their use include legal and regulatory (Kuziemko and Levitt 2004), these interventions work to approaches, such as prohibitions on the manufacture, reduce drug use and harm, including fatal and nonfatal sale, and use of opioid drugs for nonmedical purposes; heroin overdoses (Day and others 2004), as well as drug- law enforcement of these sanctions through fines and related emergency room visits (Dave 2006), by increas- imprisonment; and restricted availability of medically ing the price of illicit drugs. Alternative development prescribed drugs, such as opioids, to prevent their diver- programs in source countries do not seem to reduce sion to the black market. Interventions to increase public availability or increase prices in destination countries health and awareness include educational campaigns, (Babor and others 2010). delivered via the mass media or school-based drug However, supply interruptions often arise from a con- education programs, about the health risks of drug use vergence of circumstances that is difficult to reproduce by (table 6.1). design in different regions and drug markets. Accordingly, it is difficult to assess the cost-effectiveness of supply Control of the Supply of Illicit Drugs reduction via expensive, high-level law enforcement strat- Precursor Chemical Control. Precursor chemical reg- egies (Shanahan, Degenhardt, and Hall 2004). Nor have ulation has produced some major supply interruptions street-level law enforcement activities proven effective in (Cunningham, Liu, and Callaghan 2013).3 However, the long run, as the markets are usually displaced else- the impacts are not always predictable, and drug where, causing more harm to some groups of drug users. supply interruptions have been relatively short lived For example, heroin shortages have been linked with (ONDCP 2008). marked increases in cocaine and amphetamine injection and incident HCV infection (Strang and others 2012). Law Enforcement. The most popular interventions in many countries have been law enforcement approaches Prescription Monitoring Programs. The evidence on focusing on drug interdiction and enforcement of sanc- control of pharmaceutical opioid misuse has been domi- tions against the possession, use, and sale of illicit drugs nated by HICs. Control of pharmaceutical opioid misuse Table 6.1 Summary of Population Platforms and Recommended Interventions for Illicit Drug Dependence Universal prevention and health promotion Evidence level CEA available? Notes Legislation and regulation Precursor chemical control May be effective No Some impact, short-term; some consequences difficult to predict High-level law May be effective No Difficult to know if or when effect will occur; may be short-lived enforcement Street-level law Inconclusive No May have short-term, localized effect but leads to compensatory enforcement increases elsewhere Prescription monitoring May be effective No Poorly studied to date; may have some impact, although misuse of other programs medications may occur Information and awareness Mass media campaigns Inconclusive No Limited research with inconsistent results, with some showing negative and others positive impacts on drug attitudes and use Intersector collaboration Imprisonment Inconclusive No No evidence suggesting drug use is reduced on release, although decreased use during imprisonment Drug testing for offenders May be effective No Encouraging observational evidence from U.S. states where this has been introduced Court-mandated treatment Inconclusive No Includes mandated treatment and drug courts Note: CEA = cost-effectiveness analysis. 112 Mental, Neurological, and Substance Use Disorders likely differs in LMICs, where opioids such as morphine before trial or who are on probation or parole, and sanc- are less readily available because of excessive enforce- tions can include 24 hours of imprisonment. ment of regulations to prevent their misuse. HICs have attempted to reduce increases in the use, misuse, and Court-Mandated Treatment. Court-mandated treat- diversion of pharmaceutical opioids by implement- ment refers to treatment entered under legal coercion by ing controlled-substance laws, prescription monitoring persons who have been charged with or convicted of an systems, and clinical guidelines against overprescribing offense to which their drug dependence has contributed. (Compton and Volkow 2006). Such treatment is most often provided as an alterna- However, extramedical users may obtain pharma- tive to imprisonment—and usually with the threat of ceutical opioids in several ways, for example, doctor imprisonment if the person fails to comply with treat- shopping, informal sharing and trading of medications ment (Hall, Farrell, and Carter 2014). between peers and family members (Fischer, Bibby, Research into the effectiveness of court-mandated and Bouchard 2010), larger-scale diversion via thefts treatment is largely limited to observational studies (Inciardi and others 2007), and proliferation of online in the United States of offenders entering treatment pharmacies (Littlejohn and others 2005) that limit the under various forms of legal coercion, including beneficial effects of prescription systems. Restrictions methadone maintenance treatment (MMT). Early on one class of prescription drug may increase the use evidence of the effectiveness of such treatment comes of another class; these measures can also restrict access from a study in the United States that showed that by those who have a legitimate medical need for them among illicit drug offenders, a much greater reduction (Strang and others 2012). in heroin use and substantially lower incarceration rates were found among those enrolled in opioid sub- Public Awareness Campaigns stitution therapy (OST) in the year after release from Populationwide mass media campaigns to deliver infor- prison (Dole and others 1969). Some more recent mation and expand public awareness have not had con- observational studies support these findings (Anglin sistent impacts on use (Ferri and others 2013; Wakefield, 1988; Young, Fluellen, and Belenko 2004), but others Loken, and Hornik 2010). do not (Klag, O’Callaghan, and Creed 2005). Formal drug courts are another alternative to sus- Criminal Justice Platforms pended sentences or diversion programs; in the short Imprisonment. One consequence of the focus on law term, they can reduce future criminal offending and enforcement is that imprisonment for drug or property drug use more than conventional courts. However, offenses is the most common intervention (Strang and few randomized controlled trials have been conducted others 2012). Although imprisonment is not an effective to evaluate these (Brown 2010), and there are few way to reduce drug dependence (Manski, Pepper, and studies of the costs and cost-effectiveness of any of Petrie 2001), constructive health interventions, such as these criminal justice interventions. Of the 69 relevant hepatitis B vaccinations, can be provided in this setting studies conducted in Australia and the United States (Farrell, Strang, and Stover 2010). between 1980 and 2004 (Perry and others 2009), only Studies examining the effect of cannabis decrimi- one reported cost-effectiveness data (Schoenwald and nalization (Room and others 2010) have been method- others 1996), suggesting that the cost of treatment was ologically weak, often simply comparing the prevalence nearly offset by the savings incurred by reducing days of cannabis use before and after changes in the law. incarcerated. This area remains controversial; only weak evidence exists that tougher sanctions reduce either criminal offending in general or drug use in particular (Strang Community Platform Interventions and others 2012). Workplace Drug Testing Drug testing has been increasingly used in workplace Drug Testing of Offenders. Research has yielded settings, such as athletics, criminal justice, mining, increasing evidence that sure, immediate, and modest the military, government agencies, and health services. sanctions for positive drug tests substantially reduce Urine sampling is considered the gold standard (Phan drug use among individuals under criminal justice and others 2012) because of the accuracy, speed, ease of supervision (Kleiman 2009), but controlled evaluations administration, and limited invasiveness required. There have been limited. Typically, this evidence applies to have been limited evaluations of the impact of man- offenders who have been released into the community datory drug testing in the workplace; some supportive Illicit Drug Dependence 113 evidence is available from programs in the United States Self-Help and Mutual Aid Groups that have used drug testing with doctors and airline Self-help and mutual aid groups are run by recovering pilots (DuPont and others 2009). drug users, typically using adaptations of the 12-step principles of Alcoholics Anonymous. The groups School-Based Prevention Programs include Narcotics Anonymous, Cocaine Anonymous, Schools provide a popular setting for prevention pro- and Marijuana Anonymous. A mutual aid approach grams, because of the ready access to young adults called Self-Management and Recovery Training (SMART and the ease of intervention delivery. Evidence of the Recovery) offers an alternative choice for group-based effectiveness of school-based interventions varies widely. rehabilitation without the 12-step approach, especially Reviews of randomized controlled evaluations suggest for those who are either unwilling or unable to use that psychosocial interventions may have some benefit 12-step groups (Horvath 2000). (Faggiano and others 2014), but no evidence indicates Some individuals use these groups as their sole that interventions that only target knowledge and aware- support for abstinence; others use them in combina- ness of negative consequences of illicit drug use are tion with professional counseling and other strategies effective (Strang and others 2012). (Freimuth 2000). Although self-help is probably the most common type of intervention delivered globally Drug Education. An example of a widely used but for drug abuse, until recently there have been few sci- ineffective drug education program in the United States entific studies of its effectiveness. Observational and was the Drug Abuse Resistance Education (DARE) quasi-experimental evidence suggests that participation program, in which police officers gave classroom advice in Narcotics Anonymous is associated with continued on the dangers of drug use. Rigorous study showed that abstinence, lower health care costs, and improvement DARE neither prevented nor delayed drug use (Ennett in other areas of functioning (Gossop, Stewart, and and others 1994). Similarly, evaluation of a popula- Marsden 2008; Strang and others 2012) (table 6.2). tionwide mass media campaign targeted at youths ages 9–18 years to prevent cannabis use also showed that it had no effect and possibly increased use (Hornik and Health Care Platform Interventions others 2008). Community-Level Care Community-based strategies can potentially reduce Skills Training. School-based interventions targeting harms related to illicit drug use, especially blood-borne social skills are effective in reducing drug use and have virus (BBV) transmission and opioid overdoses. These positive effects in other domains, including reducing inter- strategies include OST, overdose prevention education, nalizing and externalizing disorders.4 The Strengthening emergency response education, and supervised injecting Families Program, targeting youths ages 10–14 years and facilities (SIFs) (table 6.3). their parents, is an evidence-based family skills training program that has been shown to reduce drug abuse and Access to Treatment. Consistent evidence from obser- other problem behaviors (Strang and others 2012). The vational studies and randomized trials shows that the Good Behavior Game, a classroom behavior management risk of death from overdose is substantially reduced approach for children ages 5–7 years that originated in in individuals while they receive OST compared with the United States and that has been tested worldwide, their risk when not receiving OST (Degenhardt, has shown positive outcomes up to 15 years after the Bucello, Mathers, and others 2011). Maximizing OST intervention (Kellam, Reid, and Balster 2008). Economic provision to drug users in the community, in prison analyses suggest that these early-age interventions are (Larney, Gisev, and others 2014), and after release from cost-effective because substantial lifetime benefits are prison (Degenhardt, Larney, and others 2014) will have realized from even modestly lower rates of early drug or demonstrable population-level effects on overdose alcohol use (Caulkins and others 2002). mortality. Early Intervention with At-Risk Youth. There is lim- Overdose Prevention Education. Polydrug use ited, low-quality, and inconsistent evidence about the increases the chances of fatal overdose, particularly the effectiveness of school-based drug testing among high concurrent use of opioids and other drugs that depress school students (Shek 2010). The evidence on the impact the central nervous system, like benzodiazepine and of psychosocial interventions for young people using alcohol (Warner-Smith and others 2001). Educating substances or at risk of doing so is limited and inconsis- people who use opioids, particularly by injection, about tent (Strang and others 2012). these dangers and the risks of injecting alone or on the 114 Mental, Neurological, and Substance Use Disorders Table 6.2 Summary of Community Platforms and Recommended Interventions for Illicit Drug Dependence Selective prevention and CEA health promotion, by platform Evidence level available? Notes Workplaces Drug testing Limited No Evidence from programs for employees with identified substance use problems Schools Drug testing Inconclusive No Inconsistent, poor evidence Drug education Sufficient No Not effective; substance use possibly even increased Skills and psychosocial Sufficient Yes Strengthening Families Program interventions with primary school Good Behavior Game: long-term effects up to 15 years children post-intervention Skills training with adolescents Inconclusive No Short-term effects at best; no effect found by some studies Early intervention with at-risk Limited No Limited, low-quality evidence with inconsistent findings; small, youth short-term effects found by some studies, but no effects found by others Community Self-help groups Limited No Narcotics Anonymous, Cocaine Anonymous, Marijuana Anonymous, SMART Recovery (amphetamines): limited RCT evidence and selection bias likely in observational studies Note: CEA = cost-effectiveness analysis; RCT = randomized controlled trial; SMART Recovery = Self-Management and Recovery Training. streets, where assistance in case of overdose is limited, Although models differ, all SIFs provide sterile injecting might reduce the risk of overdose (McGregor and others equipment and a hygienic environment where pre- 2001).5 However, the effectiveness of these strategies has obtained drugs can be injected. not been rigorously evaluated. Observational evaluations in Vancouver and Sydney have suggested that SIFs attract risky injectors, facilitate Naloxone and Other Emergency Responses. Another safe-injection education, reduce syringe sharing, and strategy is to improve bystander responses to opioid increase referral and entry into withdrawal management overdoses by encouraging drug users who witness over- and drug treatment. Although reviews suggest that doses to seek medical assistance and use simple but drug use does not change among clients or among drug effective resuscitation techniques until help arrives injectors in the areas where SIFs are located (Kerr and (Wagner and others 2010). This approach includes the others 2007; MSIC Evaluation Committee 2003), the distribution of naloxone to opioid injectors and their evidence of their impact on HIV transmission is uncer- peers. Naloxone is a narcotic antagonist that rapidly tain (Kimber and others 2010). However, reducing the reverses the effects of acute narcosis, including respira- risk among the most vulnerable injecting drug users may tory depression, sedation, and hypotension.6 An increas- increase the effectiveness of other interventions. ing number of jurisdictions have been implementing such programs, although evaluations have largely been Primary Health Care observational (Tobin and others 2009). Screening and Brief Intervention. Some evidence sug- gests that a single brief intervention in a clinical setting Supervised Injecting Facilities. SIFs are located in areas can reduce illicit drug use (Baker and others 2005; where injecting drug users are concentrated, typically Humeniuk and others 2012), although a recent system- in areas with large, open drug markets. The goal is to atic review concluded that further studies were needed reduce drug overdose deaths and BBV infections among (Young and others 2014). Brief interventions from injectors who inject in public places. SIFs have poten- prescribers, such as tailored written letters to patients tial community impact but exist in a limited number or consultations, reduced heavy benzodiazepine use up of locations, only 61 cities in eight countries (Hedrich, to six months after intervention (Mugunthan, McGuire, Kerr, and Dubois-Arber 2010; Kerr and others 2007). and Glasziou 2011). Illicit Drug Dependence 115 Table 6.3 Summary of Health and Social Care Interventions and Recommendations for Illicit Drug Dependence Intervention, by platform Evidence level CEA available? Notes Community-based care Emergency naloxone provision (opioid Limited No Becoming increasingly implemented, but evidence overdose) limited to observational evaluation Supervised injecting facilities Limited No No clear impact on drug use per se (not the intent) Primary health care Screening and brief intervention Limited No Some evidence of short-term reduction in drug use, but further studies needed Specialist health care Detoxification and withdrawal Limited No Not effective as stand-alone postwithdrawal treatment Naltrexone-accelerated withdrawal alone Limited No Not effective as stand-alone postwithdrawal treatment Medication for cannabis withdrawal alone Limited No Reduces withdrawal symptoms; no difference in long- term reduction in cannabis use Residential rehabilitation Limited No Some level II and III studiesa Brief psychological intervention CBT for cannabis dependence Sufficient No Short-term, modest impact CBT for opioid dependence Sufficient No As an adjunct to OST CBT for psychostimulant dependence Sufficient No Short-term, modest impact Acupuncture Inconclusive No Low-quality studies; no clear evidence of effect (cocaine and opioid dependence) Medications for heroin and other opioid dependence BMT Sufficient Yes Reduces risk of overdose and opioid use MMT Sufficient Yes Reduces risk of overdose and opioid use HMT Sufficient No Expensive; not first-line OST Oral naltrexone Sufficient No Effectiveness limited by poor adherence Implant or sustained-release naltrexone Limited No Potential for improved adherence, but insufficient evidence Medications for cannabis dependence Limited No Some limited benefits identified with symptomatic medications; preliminary evidence for cannabis antagonists Medications for cocaine dependence Sufficient No Not efficacious Medications for psychostimulant dependence Sufficient No Weak efficacy in trials; no evidence of effectiveness Note: BMT = buprenorphine maintenance treatment; CBT = cognitive behavioral therapy; CEA = cost-effectiveness analysis; HMT = supervised injectable heroin maintenance treatment; MMT = methadone maintenance treatment; OST = opioid substitution therapy. a. Level II studies refer to randomized controlled trials; level III studies refer to well-designed, pseudo-randomized controlled trials, cohort studies, case-control studies, or interrupted time-series studies. Specialist Health Care users seek most often. It provides users with a respite Detoxification and Withdrawal. Detoxification cen- from use, an occasion to reconsider their drug use, ters provide supervised withdrawal from a drug of and a potential prelude to abstinence-based treat- dependence with the aim of minimizing the severity ment. Detoxification has minimal, if any, enduring of withdrawal symptoms. Detoxification is not a impact on dependence on its own (Mattick and treatment, but it is the intervention that dependent Hall 1996). 116 Mental, Neurological, and Substance Use Disorders Residential Rehabilitation. Residential rehabilitation Medications for Heroin and Other can be a therapeutic community (TC) model that typ- Opioid Dependence. ically involves residency for six months and a 12-step Methadone Maintenance. Once-daily oral MMT is the approach, often after 28 days of residential treatment most common form of drug substitution worldwide that followed by community engagement in a network of is more effective than a placebo (Mattick and others 2014). 12-step groups or a faith-based approach (for exam- Large observational studies have found that patients in ple, Christian rehabilitation houses), with the aim of MMT decreased their heroin use and criminal activity abstinence from all opioid and other illicit drugs. These while in treatment. MMT substantially reduces HIV approaches often encourage patients to become involved transmission through needle sharing, and it is the best- in self-help groups, such as Narcotics Anonymous. They supported form of OST in terms of retention in treatment use group and psychological interventions to help users and reduction of heroin use (Gowing, Hickman, and remain abstinent. Degenhardt 2013; Mattick and others 2014). There have been few successful randomized con- trolled trials for TCs or outpatient drug counseling Buprenorphine Maintenance. Buprenorphine is a mixed (Vanderplasschen and others 2013). TCs are more agonist-antagonist opioid receptor modulator that has demanding of drug users and are less successful than partial agonist effects similar to those of morphine while OST in attracting and retaining drug users in treatment. also blocking the effects of pure agonists like heroin. In Nevertheless, TCs substantially reduce drug use and high doses, its effects can last up to three days, and its crime in those who remain in treatment for at least three antagonist effects substantially reduce the risk of over- months (Smith, Gates, and Foxcroft 2006). TCs may be dose and abuse. Meta-analyses of controlled trials of more effective if they are used in combination with legal buprenorphine have found it to be effective in the treat- coercion to ensure that drug users stay in treatment long ment of heroin dependence (Mattick and others 2014). enough to benefit from it (Gerstein and Harwood 1990). Morphine Maintenance. Other opioid medications have Psychosocial Interventions. been used as OST medications with success, such as Brief Intervention. Brief interventions have been found supervised OST with long-acting morphine (Mathers to be effective when provided through outreach services, and others 2010). such as needle and syringe programs. Behavioral family- and couple-based interventions have produced better Supervised Injectable Heroin Maintenance. Supervised abstinence rates in treatment and at follow-up (Strang injectable heroin maintenance treatment (HMT) has and others 2012). been evaluated in a series of trials as a second-line treatment for chronic heroin users who have repeatedly Cognitive Behavioral Therapy. Cognitive behavioral failed to respond to oral forms of opioid maintenance. therapy, particularly short-term treatments provided in Reviews suggest that HMT can increase well-being three to six outpatient sessions, have resulted in modest and reduce heroin use and criminal activity; it may abstinence rates of 20–40 percent at the end of treatment, potentially reduce mortality. The risk of serious adverse but high relapse rates and more modest abstinence rates events, however, means that HMT should be reserved for after 12 months. Psychosocial treatments for cocaine and those who have failed in other treatments and should be amphetamine dependence have limited effectiveness and provided under medical supervision (Ferri, Davoli, and high rates of relapse after treatment (NICE 2007; Strang Perucci 2011). and others 2012). Naltrexone Maintenance. Naltrexone completely blocks Contingency Management. Contingency management the effects of any opiate, such as heroin. From a clinical is a behavioral reinforcement approach that uses incen- perspective, however, oral naltrexone has been disap- tives, such as vouchers or clinic benefits, to improve pointing because of patient nonadherence (Minozzi and adherence to treatment and duration of abstinence others 2011). This finding has led to two very different (Budney and others 2006). The benefits of treatment approaches to improving adherence: (a) behavioral strat- depend on the magnitude of reward. This form of egies to improve adherence and the use of contingency intervention may work best for people with more management strategies, such as rewards for adherence, severe dependence on cocaine (Petry and others 2004). and (b) the development of long-acting naltrexone for- Contingency management also improves completion of mulations (implant or slow-release injection). The evi- hepatitis B vaccination among opioid-dependent people dence for the effectiveness of these approaches remains (Weaver and others 2014). limited (Larney, Gowing, and others 2014). Illicit Drug Dependence 117 Medications for Cannabis Dependence. No effective Caulkins and others 1999). Since these economic anal- maintenance pharmacotherapies exist for cannabis yses have been conducted almost exclusively in HICs, dependence (Danovitch and Gorelick 2012); no phar- their relevance to lower-resource contexts is limited. macotherapies have been approved for cannabis with- Nevertheless, the studies have demonstrated that these drawal. Only limited benefits are documented from interventions represent reasonable value for money trials of symptomatic medications, including antide- in these settings. In Australia, for example, MMT and pressants (Carpenter and others 2009); mood stabilizers, buprenorphine maintenance treatment (BMT) were including lithium (Winstock, Lea, and Copeland 2009); shown to produce increases in heroin-free days at an and the α2-adrenergic agonist lofexidine (Haney and acceptable and not significantly different level of cost- others 2008). effectiveness (Doran 2005; Harris, Gospodarevskaya, Oral delivery of synthetic delta-9-tetrahydrocan- and Ritter 2005). nabinol reduced a subset of cannabis withdrawal A cost-effectiveness analysis of MMT and BMT was symptoms in laboratory (Haney and others 2004) conducted in LMICs as part of the second edition of and outpatient settings (Vandrey and others 2013). Disease Control Priorities in Developing Countries (Hall Nabiximols (Sativex), a cannabis agonist, has been found and others 2006). This analysis found that MMT was in a randomized controlled trial to significantly reduce a more cost-effective option than BMT, with a year of the severity of cannabis withdrawal-related effects, healthy life generated for less than US$1,000 in the lower including irritability, depression, and cannabis cravings, prevalence settings (including Sub-Saharan Africa) and compared with a placebo (Allsop and others 2014). for US$1,000–US$10,000 elsewhere. In LMICs, where HIV is being spread by injecting drug users, MMT Medications for Psychostimulant Dependence. Despite programs can be an effective and cost-effective strategy substantial investment in research, no effective pharma- for prevention, as indicated in a study in Belarus, where cological treatments have emerged for cocaine depen- the average cost per HIV infection averted was less than dence (Amato and others 2011) or for amphetamine or US$500 (Kumaranayake and others 2004). methamphetamine dependence (Brensilver, Heinzerling, and Shoptaw 2013). Weak evidence indicates the efficacy of oral dexamphetamine maintenance (Galloway and IMPLICATIONS FOR LOW- AND MIDDLE- others 2011; Longo and others 2010). INCOME COUNTRIES Most of the research on drug dependence, its disease burden, and its societal harm has been conducted in COST-EFFECTIVENESS OF INTERVENTIONS HICs. To translate these findings into disease control FOR ILLICIT DRUG DISORDERS priorities for LMICs, we examine three sets of issues: There is evidence of the cost-effectiveness of a few country-specific variations in illicit drug use and disease interventions (tables 6.1–6.3), but there is a paucity of burden, countries’ health care infrastructure and capac- information to support resource allocation to different ity, and varying cultural attitudes toward drug problems drug policies. This lack of evidence can be attributed in and treatments. part to challenges in identifying and measuring the costs and effects of supply-side strategies or policies, such as the high-level enforcement of sanctions against illicit Issues for Assessment drug possession, use, and sale (Shanahan, Degenhardt, Illicit Drug Use and Disease Burden and Hall 2004), or criminal justice interventions (NICE Countries differ in the scale of illicit drug use and the 2007). The paucity of information also mirrors the mod- disease burden. This variation may reflect differences in est level of evidence on the cost-effectiveness of many of the prevalence of injecting versus non-injecting opioid the interventions reviewed in this chapter. A final reason and stimulant use; users’ access to health services for is the shortage of technical capacity to undertake these treating overdoses, BBVs, and other complications of studies, particularly in LMICs. drug use; access to preventive interventions for HIV Cost-effectiveness evidence is mainly available for and other BBV infections, such as needle and syringe substitution or maintenance treatment of opioid depen- programs (Mathers and others 2010); and the extent to dence using methadone or buprenorphine (Simoens which illicit drug use is concentrated in socially disad- and others 2006). One or two studies have also assessed vantaged groups. Many LMICs lack the research infra- the costs and consequences of school-based life skills structure to assess the use of illicit drugs and its harm programs on future illicit drug use (see, for example, and to evaluate the effectiveness of interventions. 118 Mental, Neurological, and Substance Use Disorders Health Care Infrastructure and Capacity and cost-effectiveness are essential to judge the appli- Societal wealth and the extent of health care infrastruc- cability of findings in HICs to LMICs. The research ture affect the capacity of countries to respond to illicit needs to include LMIC-specific evaluation of a range drug dependence. For example, a country’s capacity to of interventions, including self-help, abstinence-based provide OST is affected by the cost of opioid drugs and approaches, and oral OST. the nonexistence of infrastructure to deliver OST effec- It is particularly important to assess the effective- tively and safely. This infrastructure would include, for ness and safety of treatment delivery modifications in example, specialist drug treatment centers; trained med- LMICs that lack the quality of health care infrastructure ical, nursing, and pharmacy staff; and a drug regulatory found in HICs. Such studies may also identify novel system. In HICs, the treatment delivery infrastructure and cheaper ways to deliver these treatments in lower- includes medically trained staff and community-based resource settings. pharmacists to prescribe and dispense these drugs and control systems for the distribution of substitute opioids Potential New Treatments that minimize diversion and illicit use. There is little evi- dence to suggest the level of minimal infrastructure nec- New treatments and improved forms of existing treat- essary to deliver these treatments safely and effectively is ments could improve the modest outcomes of treatment available in LMICs. for illicit drug dependence. Technological advances are enabling researchers to develop ultra-long-acting Medical versus Moral Models of Addiction implants or injectable depot formulations of drugs. A society’s response to illicit drug use is affected by cul- These might overcome, at least in part, the major prob- tural attitudes and beliefs, including the dominant views lem of poor medication adherence and dropout. on illicit drug use and the governing cultural images of OST trials are exploring the potential for greater drug dependence (Gerstein and Harwood 1990). A crit- therapeutic gain using depot buprenorphine lasting at ical determinant is the relative dominance of moral and least a month, implant buprenorphine lasting at least medical understandings of drug dependence. six months, and ultra-long-lasting formulations of the A moral model of addiction sees drug use as opiate antagonist naltrexone as either depot injections largely voluntary and addiction as an excuse for bad (lasting a month) or implant (lasting several months). behavior that allows drug users to continue without Additional benefit might come from exploring exist- assuming responsibility for their conduct (Szasz 2003). ing medications or new formulations that are not yet According to the moral view, drug users who offend widely considered in the addiction treatment field. For against the criminal code should be imprisoned (Szasz example, several European countries have prescribed 2003). A medical model of addiction recognizes that slow-release morphine as an alternative opioid mainte- some users lose control over their use and develop nance treatment. a mental or physical disorder—an addiction—that Finally, health care providers could deliver existing requires specific treatment to become and remain treatments less expensively, thereby reaching a larger abstinent (Leshner 1997). proportion of opioid-dependent people. Buprenorphine The competition between the medical and moral per- maintenance treatment is equally effective whether given spectives is not resolved in either HICs or LMICs. These in a first-level facility or a third-level facility in Australia competing views affect the societal preference for and (Gibson and others 2003). acceptability of certain interventions, especially OST and abstinence-oriented approaches (Cohen 2003). CONCLUSIONS AND RECOMMENDATIONS Illicit drug use contributes to premature mortality and Research Needs morbidity on a global scale. The substantial economic HICs and LMICs need better estimates of the prev- costs include the health care costs of managing depen- alence of dependence. LMICs, in particular, need dence; treating drug overdoses; and addressing the well-designed prospective studies of mortality and mor- complications of BBV infections, such as HIV and hepa- bidity among illicit drug users, especially in countries titis C. Illicit drug dependence also generates substantial with high rates of HIV infection and recent substantial externalities that the burden of disease estimates do not increases in drug-related problems. include, principally, high law enforcement costs in deal- LMICs also need randomized controlled trials and ing with drug dealing, property crime, and loss of public economic and outcome evaluations of treatments for amenities (such as clean, pleasant, and quality public illicit drug dependence. Comparative data on efficacy infrastructure and environments). Illicit Drug Dependence 119 The most popular interventions in HICs have 1. Illicit drugs are defined as those covered by international involved law enforcement to interdict drug supply and drug control treaties such as the Single Convention on arrest individuals for the possession, use, and sale of Narcotic Drugs (United Nations General Assembly 1972). opioid drugs. Consequently, imprisonment for drug or 2. “Novel psychoactive substances” refer to psychoactive substances not under international control that pose a property offenses is the primary intervention for most health threat. They include substances such as ketamine, users. Treatment interventions hold the greatest promise synthetic cannabinoids in various herbal mixtures, piper- for long-term effectiveness. azines (such as N-benzylpiperazine [BZP]), products mar- The most commonly available interventions for keted as “bath salts” (cathinone-type substances such as dependence have been medically supervised detoxifi- mephedrone and methylenedioxypyrovalerone [MDPV]), cation and drug-free (abstinence) approaches. OST is and various phenethlamines (UNODC 2013). available in many countries, but coverage is typically 3. “Precursor chemicals” refer to chemicals that are used in poor (Mathers and others 2010). Opioid antagonists the manufacture of illicit drugs such as cocaine (for exam- have a niche role in the maintenance treatment of opioid ple, potassium permanganate, ethyl ether, and hydrochlo- dependence, but suffer from poor compliance and prob- ric acid), heroin (acetic anhydride, ammonium chloride, ably increase the risk of overdose on return to heroin ergot alkaloids, and lysergic acid), and ATSs (ephedrine and pseudoephedrine). Control measures for such chemicals use. Their efficacy may improve with the development typically involve regulations on their sale and distribution of long-acting depot formulations, but the evidence domestically and internationally, often requiring chemical remains limited (Larney, Gowing, and others 2014; producers to register with drug enforcement agencies and Lobmaier and others 2008). keep records of sales and customers. Communication and Most of the limited research on the effectiveness intelligence-gathering platforms (such as the Precursors and cost-effectiveness of interventions for illicit opioid Incident Communication System) are also used to alert dependence has been conducted in HICs. Three broad governments of suspicious shipments, seizures, and actual sets of issues affect the way in which these findings can and attempted diversions of precursors, and to identify be translated into disease control priorities in LMICs: emerging precursors (INCB 2014). 4. “Internalizing disorders” are mental disorders where the • Countries will differ in the scale of illicit drug use and persons suffering from the disorder keep the problem to the burden that it causes. themselves, or “internalize it.” Common examples include • Societal wealth and health care infrastructure will depression, withdrawal, and anxiety. “Externalizing disor- ders” are mental disorders that comprise negative behav- affect the capacity of LMIC societies to respond to iors that are directed toward the external environment illicit drug dependence. (such as aggression and violence), including attention- • Countries’ responses will be affected by cultural deficit hyperactivity disorder, conduct disorder, and preferences for moral and medical understandings of oppositional defiant disorder (APA 2000). drug dependence. 5. “Polydrug use” refers to the use of more than one drug or type of drug by an individual, consumed at the same time Multiple interventions have been shown to have an or sequentially. Polydrug use has several functions, includ- impact on illicit drug use and dependence, ranging ing maximizing drug effects, balancing or controlling from preventive interventions with young people to negative effects, and substituting the sought-after effects of medication-assisted interventions with people who are a primary drug when supply is low (WHO 1993). opioid dependent. The challenge is to ensure that these 6. 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Illicit Drug Dependence 125 Chapter 7 Alcohol Use and Alcohol Use Disorders María Elena Medina-Mora, Maristela Monteiro, Robin Room, Jürgen Rehm, David Jernigan, Diego Sánchez-Moreno, and Tania Real INTRODUCTION an important contributor to business opportunities and jobs in the hospitality and retail sectors and a source of Alcohol is one of the most important risk factors for revenues for governments. It also plays an important premature mortality and disability. Premature mortal- role in commercial activity linked to the hospitality ity disproportionately affects low- and middle-income industry, such as hotels and airlines, and the advertising countries (LMICs) (WHO 2011a); more than 85 percent industry. of all deaths attributable to alcohol occur in these In recent years, a few large corporations have dom- nations (Room and others 2013; WHO 2011a). This inated the international alcohol market, particularly chapter updates the chapter on alcohol in Disease Control the beer and spirits sectors. In 2009, global compa- Priorities in Developing Countries, 2nd ed. (DCP2) nies produced 67 percent of the world’s commercially (Rehm and others 2006), with new scientific evidence brewed beer; “the big four” corporations produced for interventions based on population, community, and 50 percent—AB InBev, SABMiller, Heineken, and individuals, with an emphasis on evidence from LMICs. Carlsberg (Impact Databank 2011). A similar trend has Alcoholic beverages vary with respect to their raw been observed in the spirits sector, with Diageo and material, method of production, alcohol content, and Pernod Ricard managing some of the world’s leading presentation. Beverages are usually classified as fermented brands (Babor and others 2010). These companies are or distilled. In addition to the alcohol that appears in offi- headquartered in high-income countries (HICs), which cial statistics, many countries have a substantial amount are the leading exporters of alcoholic beverages, but of unrecorded alcohol, which may include illegally pro- about 95 percent of alcoholic beverages are produced duced or smuggled alcohol products, but also surrogate locally (WHO 1999). alcohol (nonbeverage alcohol not officially intended for The size of these corporations allows them to devote human consumption) and legal but unrecorded alcohol considerable resources, directly or indirectly, to pro- products (Lachenmeier, Sarash, and Rehm 2009). mote the industry’s policy interests. For example, the alcohol producers and their nonprofit organizations are Role of Industry involved in collecting, funding, and providing scientific The alcohol industry is diverse and includes beer, wine, evidence to inform the public, as well as sponsoring pre- and spirits producers and importers, as well as bars, vention activities (Zhang and Monteiro 2013), especially restaurants, and often stores that sell alcohol. Alcohol is those known to have no or small effects on behavior Corresponding author: María Elena Medina-Mora, Instituto Nacional de Psiquiatría Ramón de la Fuente (Ramón de la Fuente National Institute of Psychiatry), México; medinam@imp.edu.mx. 127 (Babor, Robaina, and Jernigan 2014). These activities behavior and inattention of drinkers while intoxicated, challenge the public health sector and governments to resulting in acts of violence, driving while impaired, respond with public health strategies to minimize the inconsistent family environments affecting normal child adverse health and societal consequences of the expand- development, and workplace absenteeism (WHO 2014a). ing global markets in alcoholic beverages (Babor and An additional and increasingly significant conse- others 2010). quence of maternal drinking during pregnancy is fetal The high level of globalization has significant effects alcohol syndrome (FAS), a pattern of retarded growth on markets. Transnational companies own the formulas and development, both neuropsychological and physical, and grant licenses to local subsidiaries. Most product with typical facial dysmorphic features, that is found is development targets external markets, and adver- some children exposed to alcohol in utero. A spectrum tising is usually produced externally. Transnational of physical and neurodevelopmental abnormalities, companies, supported by these economic advantages, which includes FAS, that is attributed to the effects of are dynamic promoters of modifications in local alcohol on the fetus, is termed fetal alcohol syndrome drinking practices, including the types and quantity of disorders (FASD). The level of maternal alcohol con- beverages consumed (Room, Jernigan, Carlini, Gmel, sumption required to produce FASD, which has yet to be and others 2013; Room, Jernigan, Carlini, Gureje, and established, is influenced by genetic and other maternal others 2002). and fetal characteristics (Gray, Mukherjee, and Rutter 2009; May and Gossage 2011). Alcohol’s impact on disease and injury is associated Public Health Considerations with two dimensions: the overall volume consumed and The substantial health and societal costs of alcohol con- the drinking patterns of how the volume is distributed sumption outweigh its economic benefits and contribute by drinking. Heavy drinking episodes have particularly to the view of public health professionals that alcohol damaging effects. The consequences associated with a cannot be considered an “ordinary commodity” (Babor high volume of drinking or recurrent heavy drinking and others 2010). Special policies are needed to curb the occur through three mechanisms: toxic and other effects consequences of harmful use, especially in LMICs where on organs and tissues, behavior during intoxication, and the burden is higher. alcohol dependence and other alcohol-induced mental This public health perspective has received little disorders (APA 2013; WHO 1992, 2013a). attention in international negotiations concerning trade agreements and in resolutions of disputes under those The Burden agreements (Room, Jernigan, Carlini, Gmel, and others 2013; Room, Jernigan, Carlini, Gureje, and others 2002). Patterns of Alcohol Use and Trends This lack of attention reduces the ability of LMICs to One of the most commonly used indicators of overall ensure the internal regulation of markets (Grieshaber- alcohol consumption and comparison by location is Otto, Schacter, and Sinclair 2006; Zhang and Monteiro per capita consumption. Although it is the best estimate 2013). Governments in LMICs are deterred or forced to available, it contains a substantial element of uncer- abandon alcohol controls as a result of trade disputes; tainty, which increases where there are large proportions for example, Thailand faces opposition from some of unrecorded production, which is more common in World Trade Organization members to its proposed LMICs. graphic warning labels on containers of alcohol sold Globally, per capita alcohol consumption in 2012 was within its borders (O’Brien 2013). an estimated 6.2 liters of pure alcohol by persons ages 15 years and older (WHO 2014a); 24.8 percent is con- sumed as unrecorded alcohol (Lachenmeier, Sarash, and ALCOHOL-RELATED DISORDERS Rehm 2009; WHO 2014a). In general, HICs have the highest levels of per capita Patterns of Alcohol Use, Alcohol Use Disorders, and consumption and often the highest prevalence of heavy Fetal Alcohol Spectrum Disorders episodic drinking. The prevalence of heavy episodic Alcohol is a major contributor to mortality, morbidity, drinking among adolescents ages 15–19 years mirrors and injuries. It is a causal factor in more than 60 diseases, that of the adult population, with the highest rates in the including liver cirrhosis and cardiovascular disease, and World Health Organization (WHO) regions of Europe, it is involved in the etiology of more than 200 other con- the Americas, and the Western Pacific (WHO 2014a). ditions, such as neuropsychiatric conditions and diabetes Altogether, women drink less than men and have mellitus. It also affects other people through the risky a lower prevalence of alcohol use disorders (AUDs); 128 Mental, Neurological, and Substance Use Disorders in 2010, 52.3 percent of men and 71.1 percent of women specialized clinics. This situation calls for a shift of focus did not drink alcohol in the previous year (WHO to cost-effective early interventions (Benegal, Chand, and 2014a). Weekly heavy episodes are also more prevalent Obot 2009). among men than women, 21.5 percent and 5.7 percent, respectively (WHO 2014a). Despite these lower rates of Unintentional Injuries and Violence. Social conse- consumption, women in LMICs suffer greater social con- quences are also salient. Road traffic injuries cost LMICs sequences per liter consumed, since this activity is often an estimated 1 to 2 percent of their gross domestic seen as inconsistent with their traditional roles (Medina- product (GDP) (WHO 2014a). Mora 2001). The highest regional prevalence of AUDs for Harmful alcohol use is a major contributor to vio- women was in the Americas; the highest regional preva- lence. The alcohol-attributable portion of total violent lence for men was in Europe (WHO 2014a). deaths is approximately 30.0 percent: 32.5 percent in Global per capita consumption of alcohol is increas- men, and 20.1 percent in women (WHO 2011a). Many ing, driven particularly by increases in China and India, perpetrators consume alcohol prior to assaults, with as well as the Americas. The five-year trend in the WHO rates reported in special studies varying from 35 percent regions of Africa and Europe is stable, although some in the United States to 50 percent in China. Men are countries in these regions report significant reductions more likely than women to drink alcohol and to be (WHO 2014a). perpetrators and victims of alcohol-related violence. For suicide, 11 percent of global mortality is attributed to Consequences alcohol, ranging from 2 percent in the Middle East and Estimations made by the WHO indicate that the pro- North Africa to 31 percent in Europe and Central Asia. portion of deaths attributable to alcohol (5.9 percent) Injuries and social consequences are particularly is higher than the proportion observed for HIV/AIDS related to patterns of drinking. A Patterns of Drinking (2.8 percent), violence (0.9 percent), and tuberculosis score developed by Rehm and others (2003) measures (1.7 percent). Alcohol plays a prominent role in liver this as a reflection of how people drink, a separate cirrhosis, oral cavity and pharynx cancer, pancreatitis, dimension of what total volume of alcohol they drink. and laryngeal and esophageal cancer. Alcohol also plays Given the predominance of men among those drinking a role in intentional injuries from interpersonal violence, heavily in many cultures, the score may be predominantly self-harm and poisoning, and unintentional injuries and comparing men’s patterns of drinking (Gmel and others falls. Harmful use and dependence ranged from 0.1 to 2007). The score reflects how much of total consumption 3.4 percent (WHO 2014b). occurs on intoxicated occasions. The score includes the Mortality. The Global Burden of Disease Study 2010 usual quantity of consumption, whether there is festive project (Murray and others 2012) estimated that alcohol drinking, the proportion of events when drinkers get as a risk factor increased from 1,988,502 deaths in 1990 drunk, the proportion of drinkers who drink daily or to 2,735,511 in 2010, a (crude) increase of 37.6 percent. nearly daily, and the proportion who drink with meals According to Lim and others (2012), alcohol is the and in public places. Two attributes, drinking with meals leading risk factor for death in Eastern Europe, Andean and drinking daily or almost daily, are scored negatively, Latin America, and southern Sub-Saharan Africa, and as reducing risk per liter. Low-risk patterns (risk score worldwide for people ages 15–49 years. lower than 3) are usually found in upper-middle-income countries and HICs; more than 95 percent of LMICs Disability-Adjusted Life Years. The WHO estimated the have a risk score of at least 3 (WHO 2014a). proportion of disability-adjusted life years accounted for by alcohol as a cause. Neuropsychiatric disorders rank Disparate Burden. Within countries, there are generally first (24.6 percent of all disability-adjusted life years), more drinkers, more drinking occasions, and more mainly caused by AUDs, followed by unintentional drinkers with low-risk drinking patterns in the highest injuries (20.4 percent), and cardiovascular diseases and socioeconomic groups, and more abstainers in the lowest diabetes collectively (15.5 percent). Globally, AUDs occur socioeconomic groups (WHO 2014a). However, drink- among 7.2 percent of men and 1.3 percent of women ers in the lower socioeconomic groups are more likely (WHO 2014a). to drink at higher levels of risk, with high quantities It has also been estimated that in LMICs, most of per drinking occasion (Room, Jernigan, Carlini, Gmel, the harm is related to hazardous or harmful drinking and others 2013; Room, Jernigan, Carlini, Gureje, and rather than to alcohol dependence. This behavior is not others 2002), and they are more vulnerable to the conse- often identified and treated within the first level of care; quences, at least partly reflecting their lower resources to treatment for alcohol dependence is usually provided in cope with consequences and pay for treatment. Alcohol Use and Alcohol Use Disorders 129 Many LMICs have higher alcohol-attributable mor- previous exercises that reviewed the existing evidence tality rates than HICs, despite the higher consumption (Babor and others 2010; Room, Jernigan, Carlini, Gmel, in HICs. This can be explained by the fact that the harm and others 2013; Room, Jernigan, Carlini, Gureje, and derived from each liter of alcohol consumed is much others 2002; WHO 2008, 2011b). greater because of a riskier pattern of alcohol consumption, The search process consisted of an electronic a larger proportion of use of unrecorded alcohol, and the review of the following databases: Medline (1994– types of disorders with which alcohol is associated, with 2013), Embase (1994–2013), PsycINFO (1966–2013), unintentional injuries the most salient (Room, Jernigan, Ovid (1970–2013), National Institute on Drug Abuse Carlini, Gmel, and others 2013; Room, Jernigan, Carlini, Database, SciELO (1994–2013), EBSCO (1994–2013), Gureje, and others 2002). In a lower-income country, the ISI Web of Knowledge (1994–2013), National Institute built environment—for example, roads and footpaths— for Health and Care Excellence evidence search, Global tends to offer less protection from injuries. Information System on Alcohol and Health, CINAHL, and Mental Health Gap Action Programme (mhGAP). The review resulted in identifying 42 articles; 21 addi- Societal Responses tional records were identified through other sources. Of Societies have used different strategies to cope with the 63 articles screened, 18 were excluded because they alcohol-related problems, depending on the specific ways did not use a robust design; 45 were selected and assessed in which the problem has been conceptualized. Strategies for eligibility, but three were excluded because of meth- vary from total to partial bans on alcohol and from highly odological limitations (Moher and others 2009). regulated markets to infrequent enforcement of the few Population-based interventions are usually evaluated existing regulations. Policies based on a combination of by before-and-after population surveys, analyses of alcohol control and medical traditions—including nor- archival and official statistics, time-series analyses, mative measures to control availability and promote a safe qualitative research, and quasi-experimental studies. environment for drinkers and the general population, as Quasi-experimental studies involve before-and-after well as the prevention and treatment of the disorder—have measurements of communities or jurisdictions exposed had significant success in holding down rates of problems to the intervention, compared with similar communities in HICs (Babor and others 2010). In LMICs, except those or jurisdictions where the intervention has not been with a strong religious tradition that rejects drinking, the implemented. situation appears more challenging and offers few mitigat- Natural experiments take advantage of the imple- ing factors. Controls on the alcohol market that existed in mentation of a new policy to test the effects; accordingly, many countries have been swept away, often by mandates they lack the random assignment of communities to the from international aid agencies for market deregulation interventions being tested and so provide a lower level of or privatization or as a result of trade disputes under free- evidence. Randomized controlled trials (RCTs), consid- trade agreements (Room, Jernigan, Carlini, Gureje, and ered the gold standard for evaluating the effect of health others 2002). In many cultures, drunkenness is often tol- interventions, are rarely used to test population-based erated, and regulations are not widespread; nevertheless, interventions (Babor and others 2010). Although important lessons can be drawn from experiences where individual-based interventions are more suitable for intervention measures have been used. RCTs, they must meet rigid standards to be considered robust (Guyatt and others 2011). Interventions at a populationwide level that do not use CHOICE OF INTERVENTIONS experimental methodology were assessed using less strin- The interventions in this chapter were identified with gent criteria, so quasi-experiments and natural exper- reference to a standardized matrix developed at a meet- iments were rated as very good (+++) or good (++), ing of the volume editors and lead authors. The matrix depending on the strategies for data analysis. Time-series divides interventions into three main groups: analysis or statistical modeling were considered to have a very good level of evidence. Other strategies, such as key • Population platform interventions, including univer- informants or reports where information was lacking, sal prevention (IOM 1998) were rated as limited + and not included in the analysis. • Community platform interventions Community and health and social care interventions • Health care platform interventions. were assessed using primarily the Grading of Recom- mendations Assessment, Development and Evaluation This mapping exercise updates the DCP2 chapter on (GRADE) guidelines. Using these, RCTs are regarded as alcohol (Rehm and others 2006) and draws on three key having high quality (very good +++). When only some 130 Mental, Neurological, and Substance Use Disorders criteria included in the GRADE guidelines were used, the the determination of whether it has been legally pro- rank was lower (good ++). Studies with limitations in the duced and sold, and the collection of taxes. Settings in methods (the sample size or follow-up period assessment), which unrecorded alcohol is highly available require inconsistencies (low reliability due to low variable control), additional controls. The following section describes lack of directedness (use of surrogate variables), or impre- evidence for these measures by region; tables 7.1, 7.2, cision (confidence intervals not reported) were ranked as and 7.3 provide additional information. having a lower level of evidence (limited +). Only articles rated as very good or good were included in this review. Prohibition, Rationing, and Partial Bans Bans on sales, when effectively enforced, have proved effective in reducing consumption and harm. However, POPULATION PLATFORM INTERVENTIONS evidence suggests that these measures encourage the black market, which is difficult and expensive to Reducing the Availability of Alcohol eliminate (Lachenmeier, Taylor, and Rehm 2011). To control the physical availability of alcohol, gov- Several experiments on prohibitions and bans have ernments need to be able to control its production, been conducted in recent years, showing a reduc- distribution, and sale. This control can be achieved tion in use, followed by an increase when controls by prohibition, monopolization, or other measures were abolished (Room, Jernigan, Carlini, Gmel, and grouped in three clusters: others 2013; Room, Jernigan, Carlini, Gureje, and others 2002). • Limiting the availability by means of taxes and min- imum prices Indigenous Communities. Margolis and others (2011) • Limiting advertising and promotion studied four remote Australian Indigenous communities; • Constraining access by licensing producers and three implemented prohibition, and the fourth allowed wholesalers and retailers: when and where beverages low-alcohol beer within licensed premises. Serious can be available, to whom can they be sold, and how injury rates declined in all four communities. Similar they can be sold. results were observed in the First Nation Communities in Canada (Gliksman, Rylett, and Douglas 2007). The Licensing systems facilitate the enforcement of reg- remoteness of the communities studied is likely to have ulations, the assessment of the origin of the alcohol, enhanced the effectiveness of the intervention. Table 7.1 Population-Based Interventions to Reduce Alcohol Availability Population Type of study Main results Prohibition, rationing, and partial bans Indigenous communities/Australia Doctor service data, quasi-experimental (+++) Prohibition and allowance of low-alcohol beer at and Canada licensed premises reduced serious injury (Gliksman, Rylett, and Douglas 2007; Margolis and others 2011). Latin America/Venezuela, RB National statistics, quasi-experimental time- Restriction intervention (“dry laws”) reduced use and series analysis, modeling (++) accidents (Herrera and others 2009). Taxation East Asia/Thailand Data from alcohol producers, national alcohol Taxation on distilled spirits led to a reduction in use surveys and statistics; theoretical evaluation, overall consumption (Chaiyasong and others 2011; simulation and empirical analysis; price elasticity Sornpaisarn, Shield, and Rehm 2012); prevented the analysis; quasi-experimental, time lapse analysis onset of drinking among youth (ages 15–24 years) (+++) (Sornpaisarn and others 2013); but use of beer rose as a substitution effect (Chaiyasong and others 2011). East Asia and Pacific/China, Systematic review, PRISMA (+++) Twelve studies showed evidence of a link between Thailand; Central and South Asia/ alcohol prices or taxation and consumption in LMICs; Turkey and India; Sub-Saharan unrecorded alcohol was not considered (Sornpaisarn Africa/Kenya, Tanzania and others 2013). Note: LMICs = low- and middle-income countries; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; ++ = good; +++ = very good. Alcohol Use and Alcohol Use Disorders 131 Table 7.2 Restrictions on Alcohol Sale and Advertising: Density, Hours, Days, and Locations Population Type of study Main results Indigenous communities/ Data from admissions to local After two years of constraints on the days, hours, and amounts Australia hospitals, women’s refugee centers, of different beverages allowed for sale, annual per capita sobering-up shelters, and police consumption of pure alcohol (19.4 percent) and hospital admissions records; time-series analysis, quasi- declined (Gray and others 2000). experimental (+++) Latin America and the Caribbean/ Police records; time-lapse analysis on A significant reduction in violence was reported in Brazil following Brazil, Colombia, and Peru homicides; linear regression analysis, the implementation of a municipal law preventing the sale of quasi-experimental (+++) alcohol after 11 p.m., followed by a public information campaign (Duailibi and others 2007). Similar results have been observed through restrictions on alcohol service hours in cities in Colombia (Sánchez and others 2011) and Peru (Málaga and others 2012). Note: +++ = very good. Table 7.3 Law Enforcement Measures to Reduce Impaired Driving Population Type of study Main results East Asia and Pacific/China Serial cross-sectional telephone surveys; time-lapse Random breath tests reduced impaired driving analysis; liquor sales; quasi-experimental (+++) rates (Kim and others 2013). Arrests of impaired drivers who exceeded blood alcohol limits were associated with a reduction in fatal accidents in Taiwan, China (Chang and Yeh 2004). Latin America and the Caribbean/Brazil Representative sample of trauma care centers; Low blood alcohol rates reduced traffic injuries time-series analysis, quasi-experimental (+++) and deaths (Andreuccetti and others 2011). Note: +++ = very good. Latin America and the Caribbean. The impact of par- Taxation tial bans on alcohol consumption on traffic accidents The effects of taxation can be measured by price elastic- and injuries was evaluated in República Bolivariana ity, which reflects the change in consumption in relation de Venezuela during one week of national holidays to the size of the price increase (percentage of change in (Herrera and others 2009). During the week the law was quantity purchased/percentage change in price); an elas- in effect, alcohol use was reduced and fewer accidents ticity of less than –1.0 indicates that demand is relatively were reported. responsive to changes in price or is “elastic.” Elasticities Alternative solutions to prohibition include measures between –1.0 and 0 indicate that the demand is less to regulate the alcohol market. Evidence has shown that responsive to prices or is “inelastic” (NIAAA 2000). An alcohol consumption and related problems decrease inelastic response to a tax increase may still have positive when accessibility is diminished (for example, by pric- public health effects. ing alcohol higher than other products) and consump- Evidence, mostly from HICs, shows a range of elastic- tion is more difficult (for example, by limiting the hours ities from –0.3 for the beverage ranked first in the target of sale). Alcohol prices may be increased through taxes, population’s preferences to –1.5 for the one ranked last curbing consumption problems while increasing gov- (Rehm and others 2003). Accordingly, an elasticity of –0.3 ernment revenues. Evidence has shown that this mea- with respect to a tax on alcohol means that consumption sure impacts heavy drinkers (defined as an average of will be reduced 3 percent by a 10 percent tax increase, more than 20 grams of pure alcohol per day for women while the alcohol tax revenue for the government will rise and more than 40 grams for men) and light to moderate by 6.7 percent. drinkers (less than 20 grams for women and less than 40 grams men), as well as younger and older drinkers Latin America and the Caribbean. In Mexico, the price (underage and legal age) (Babor and others 2010). elasticity of demand was near –0.2 (Galindo, Robles, 132 Mental, Neurological, and Substance Use Disorders and Medina-Mora 2012); in República Bolivariana de concern for controling unrecorded alcohol is that it can Venezuela, the price elasticity was quite low, between undercut the effects of regulatory measures by offering –0.074 and –0.058 (Herrera and others 2009). people an alternative. Some successful control exam- ples include the centuries-old requirement of official East Asia and Pacific. In China, using data from the sealing labels over corks or stoppers; this measure has China Health and Nutrition Surveys for 1993, 1997, been widely used, and the attendant threat to withdraw 2000, 2004, and 2006 in nine provinces in China, the the liquor license of any place caught using untaxed price elasticity was virtually zero for beer and only −0.12 alcohol has been effective (Lachenmeier, Rehm, and for liquor (Tian and Liu 2011). A previous estimate Gmel 2007). derived from household surveys conducted in 1993 and Another concern about unrecorded alcohol is its poten- 1998 in three main cities and one province of China tial toxic effects. Although according to Lachenmeier, found elasticities of –0.51 for wine coolers, –0.85 for Rehm, and Gmel (2007) the contribution of these effects beer, and –1.39 for wine (Pan, Fang, and Malaga 2006). to mortality is still unclear, because of their public health Using time-series data for consumption and retail prices importance some measures to reduce harm can be in Taiwan, China, the price elasticity for alcohol was included in policies. For example, such measures could –0.771 (Lee and others 2010). include abolishing denatured alcohol; abolishing the use A study conducted in Thailand showed the effective- of methanol, which is a simple form of alcohol closely ness of two taxation approaches (Sornpaisarn, Shield, related to ethanol and found in unregistered alcoholic and Rehm 2012). One tax schedule is based on alcohol beverages, but more toxic (Pincock and ABC Health & content, aimed at discouraging harmful patterns by Wellbeing 2013); or treating products not intended for promoting beverages with low alcohol content, suitable human consumption with bittering agents to prevent for contexts with a high prevalence of current drink- people from using them (Lachenmeier, Rehm, and Gmel ers. The other tax scheme is estimated as a function of 2007). For example, recently in Mexico, after an increase price, which increases taxes on beverages consumed by in the number of seizures of unrecorded alcohol, a new heavy drinkers and potential new drinkers. Since the regulation was issued requiring that all ethyl alcohol first scheme has the potential risk of promoting con- and methanol produced in the country be mapped to sumption in abstainers who are a large segment of the the primary manufacturing process. This regulation population in LMICs (WHO 2013a), a combination prevents diversions to informal channels, where unre- of both measures is proposed, together with interven- corded alcohol can be mixed with alcoholic beverages. tions designed to control the promotion of alcoholic The regulation prohibits the sale of alcohol in bulk beverages. and the incorporation of methanol as a raw product in beverages (CSG 2014). East Asia and Pacific, South Asia, and Sub-Saharan Following a review of policy options for regulating Africa. In a systematic literature review and meta- unrecorded alcohol, Lachenmeier, Taylor, and Rehm analysis, Sornpaisarn and others (2013) found 12 stud- (2011) classified policies in: ies with evidence of the link between alcohol prices or taxation and consumption in LMICs (China, India, • Reducing health risks: prohibiting the toxic com- Kenya, Tanzania, Thailand, and Turkey), although pounds that are used to denature alcohol and sub- unrecorded alcohol was not considered. Elasticity esti- stituting them with substances with acceptable toxic mates were –0.64 (95% confidence interval [CI]: –0.80 profiles, for example, via the use of bittering agents, to –0.48) for total alcohol consumption, –0.50 (95% to prevent accidental deaths CI: –0.78 to –0.21) for beer consumption, and –0.79 • Reducing cross-border shopping: narrowing tax differ- (95% CI: –1.09 to –0.49) for consumption of other ences between unrecorded and recorded beverages or alcoholic beverages. They concluded that the price introducing stricter controls elasticity of demand for alcohol in LMICs is similar to • Limiting illegal trade and counterfeiting: implement- that in HICs, and suggested more research was needed ing tax stamps and electronic surveillance systems for on the association between alcohol price or taxation the alcohol trade. and alcohol-related harm and drinking initiation in LMICs. These authors also suggested that the introduction of education campaigns could increase awareness of the Control of the Unrecorded Market risks associated with drinking illegal alcohol. They con- Quantitative studies of the effects of policy options for cluded that the most problematic category was the con- controlling the unrecorded market are scarce. The main trol of home and small-scale artisanal production; the Alcohol Use and Alcohol Use Disorders 133 most promising option was to offer financial incentives accompanied by declines in hospital admissions (Gray to producers to ensure registration and quality control. and others 2000). There is a need for further research in countries with In HICs that have banned advertising, an econometric different cultures and traditions (Lachenmeier, Taylor, analysis showed that these measures had only a modest and Rehm 2011). effect on alcohol use (Rehm and others 2006). However, other research indicates that banning advertising, accom- Minimum Prices and Bans on Discounts and panied by taxation and availability restriction, combine to Promotions constitute the best buy in reducing alcohol-related prob- Evidence in HICs suggests that price discounts—such lems (WHO 2014a). Research on restrictions on advertis- as happy hours and grocery store promotions—increase ing has not been replicated in LMICs. However, research consumption and that higher prices for distilled spirits from Taiwan, China, has replicated findings from HICs shift consumption to beverages with lower alcohol con- showing that exposure to alcohol marketing is associated tent, resulting in lower total intake. Enforcing minimum with greater likelihood of initiation and persistence of prices for a standard unit of alcohol is one of the most drinking among youth (Chang and others 2014). effective ways to reduce alcohol-related problems (Babor and others 2010). No evidence is available for LMICs. Countermeasures to Alcohol-Impaired Driving The harmful consequences of alcohol can be curbed Restrictions on Density, Hours, Days, Locations of by risk-reducing measures, such as drinking and Sale, and Advertising impaired driving countermeasures. Impaired driving Control of the physical availability of alcohol through laws, when accompanied by strategies for reinforcing measures such as restricting the hours, days, and loca- them, such as regular random breath testing of drivers, tions of sale; limiting the density of concentration of have been shown to reduce the number of fatal and non- retail drinking establishments and off-sales stores (shops fatal traffic injuries. These strategies modify the drinking licensed to sell alcoholic beverages for consumption practices of high-risk alcohol users and protect other off the premises); and establishing a minimum legal members of the population, such as passengers, other purchase age have diminished alcohol use and related drivers, and pedestrians. problems in HICs (Babor and others 2010). Although such measures have also been implemented • Various blood alcohol concentration (BAC) limits in LMICs, only a few impact studies have been identified are in place globally. Setting and enforcing legisla- in these settings. tion on BAC limits of 0.05 grams per deciliter (g/dL) can lead to significant reductions in alcohol-related Latin America and the Caribbean. A significant reduc- crashes (Babor and others 2010). Setting lower tion in violence was reported in Brazil following the BAC limits (0.02 g/dL or less) or zero tolerance is implementation of a municipal law preventing the sale recommended for inexperienced drivers and young of alcohol after 11 p.m. Enactment of this law was fol- adults as an effective means of reducing crashes lowed by a public information campaign, the law was related to impaired driving; HICs are more likely strictly enforced, and the measure was assessed by an to have these laws in place than LMICs. These laws interrupted time-series analysis. The results suggest that are more effective when random breath testing for the law prevented an estimated 319 homicides over three all drivers is conducted, and when drivers perceive years (Duailibi and others 2007). Similar results have a high likelihood of being arrested if they break the been observed through restrictions on alcohol service law (WHO 2013b). hours in cities in Colombia (Sánchez and others 2011) • Rehm and others (2006) estimated that random breath and Peru (Málaga and others 2012). testing could reduce fatalities between 6 and 10 percent if partially implemented, and up to 18 percent if imple- Indigenous Communities. Some studies are available mentation were extended. For nonfatal injuries, they for indigenous groups within HICs. A study conducted calculated a reduction of 15 percent. However, these in Tennant Creek in the Northern Territory, Australia, estimates are based on information obtained from assessed the effectiveness of interventions and com- HICs, where road infrastructure and driving patterns munity attitudes toward increased restrictions on the may significantly differ from those in LMICs. availability of alcohol that included constraints on • A related measure—sobriety checkpoints—has a high the days, hours, and amounts of different beverages level of research support, with a robust, although allowed for sale. After two years, annual per capita lower, level of evidence of effectiveness in HICs consumption of pure alcohol declined by 19.4 percent, (Babor and others 2010). 134 Mental, Neurological, and Substance Use Disorders • Administrative license suspension for driving under the setting of rules and norms, and modeling behavior the effects of alcohol, allowing licensing authorities within families, yet have little impact on behavior on their to suspend a driver’s license without a court hearing own. In LMICs, some interventions have been imple- at the time of the offense or shortly after, has a good mented to help families cope with members who have level of evidence; when punishment is swift, effec- developed disorders, but the research designs used to eval- tiveness is increased, particularly in countries where uate interventions for substance use disorders have not it is consistently applied (Babor and others 2010). included clinical trials (Natera and others 2011; Tiburcio Evidence in LMICs is scarce. and Guillermina 2003). Outcomes are more compelling when family programs are combined with the other mea- East Asia and Pacific. Studies conducted in China found sures described in this chapter (Babor and others 2010). that random breath tests and the perceived potential legal consequences of conviction reduced impaired driving rates (Kim and others 2013). The arrest of intoxicated Mass Media Campaigns drivers on BAC limits and enforcement were associated Awareness initiatives include mass media campaigns. with a reduction of fatal accidents involving impaired When combined with policies and regulatory controls, driving in Taiwan, China (Chang and Yeh 2004). awareness campaigns can help to increase public support for policy measures and compliance with laws and regu- Latin America and the Caribbean. In Brazil, low BAC lations. Warning labels related to drinking during preg- rates reduced traffic injuries and deaths (Andreuccetti nancy have been introduced in HICs and LMICs. A review and others 2011). of published literature testing the effectiveness of alcohol warning levels in the prevention of FASD in Canada, COMMUNITY PLATFORM INTERVENTIONS France, New Zealand, and the United States showed that although alcohol warning labels are popular, their effec- The impact of this measure is generally evaluated in tiveness in changing behavior is limited (Thomas and terms of knowledge and attitudes. The most common others 2014). FASD, whether complete or incomplete, is target group is young drinkers; school-based interven- a growing problem that warrants further attention. There tions are one of several education and persuasion initia- is insufficient evidence, even in HICs; however, studies tives tested. show that warning labels, when delivered through chan- nels that are perceived to be useful, can be beneficial and Indigenous Communities can influence behavior if they are part of a comprehensive The effectiveness of web-based alcohol screening versus strategy (Wilkinson and Room 2009). web-based screening and a brief intervention for reduc- The mhGAP (WHO 2008) recommends advising ing hazardous drinking was tested in Maori university women who are pregnant, breastfeeding, or planning students, an indigenous population from New Zealand. to become pregnant to avoid alcohol completely, and The study used a parallel, double-blind, multisite RCT offering social support services for those who require with a five-month follow-up assessment. The results additional assistance (WHO 2014b). Treatment in some indicated that the web-based screening and brief inter- cases could be helpful. vention reduced hazardous and harmful drinking among Studies in South Africa show that treatment using non-help-seeking respondents (Kypri and others 2013). case management interventions to reduce alcohol intake Babor and others (2010) concluded from their review among high-risk pregnant women had positive effects. that the effects of the interventions on the onset of The effects included stopping drinking, changing drink- drinking and on drinking problems are equivocal and ing behavior reflected in reduced Alcohol Use Disorders minimal. Evidence shows that classroom education may Identification Test scores, and reducing problem drink- increase knowledge and change attitudes, but it has no ing (Maraisa and others 2011) (table 7.4). long-term effect on drinking behavior. Similar results were observed in college students exposed to a multi- component program comprising mass media campaigns and impaired driving campaigns, warning labels, and HEALTH CARE PLATFORM INTERVENTIONS social marketing. Screening and Brief Interventions Key elements of brief interventions include feedback, Family-Based Interventions responsibility, advice, strategies, empathy, and self- Family interventions have improved communication efficacy. Strong evidence supports clinically signifi- skills, parental supervision of children and adolescents, cant effects on drinking behavior and related problems Alcohol Use and Alcohol Use Disorders 135 Table 7.4 Community-Based Interventions: School and Family Interventions and Media Campaigns Population Type of study Main results Indigenous communities/Maori in Parallel, double-blind, multisite RCT with a Web-based screening and brief intervention reduced New Zealand five-month follow-up assessment (+++) hazardous and harmful drinking among non-help- seeking respondents (Kypri and others 2013). South Africa Pragmatic cluster randomized trial with no Treatment using case management interventions to evidence of a diagnostic test used in the reduce alcohol intake among high-risk pregnant women assessment phase (++) reduced risk (Maraisa and others 2011; Rendall-Mkosi and others 2013). Note: RCT = randomized controlled trial; ++ = good; +++ = very good. (Diaz and others 2011; Nagel and others 2009). The Table 7.5 Screening and Brief Interventions in mhGAP Intervention Guide (WHO 2011b) identifies Low- and Middle-Income Countries three levels of interventions with individual problematic Site Main results drinkers: Thailand (++) Motivational interviewing was tested in low- • Screening and brief interventions by trained primary resource settings (Noknoy and others 2010; health care professionals Segatto and others 2011). • Early identification and treatment of AUDs in pri- China (+++) Counseling was supported with health promotion mary health care booklets (Tsai and others 2009). • Referral and supervisory support by specialists. Brazil (+++) Brief advice was provided on cognitive behavioral interventions (Marques and Formigoni The WHO mhGAP action plan promotes scaling 2001). up services for mental, neurological, and substance use Mexico (++) Motivation therapy showed a greater reduction disorders, with more cases treated at the first level of of alcohol use compared with cognitive care (WHO 2008). The program is based on a review behavioral therapy (Diaz and others 2011). and evaluation of the strength of the evidence to submit Indigenous Brief psycho-educational intervention that recommendations for action. Psychosocial support was communities/ included motivational care planning, problem found to be more effective than no treatment, while Australia (++) solving, and impulse management showed motivational interviewing and motivation enhancement significant benefits, compared with a control were possibly more effective than standard psychoso- group (Nagel and others 2009). cial treatment involving families and friends (mainly Kenya (++) Intervention was among people with HIV/AIDS spouses), or no treatment, or individual counseling. (Papas and others 2010). Evidence in LMICs is widespread and consistent, Note: ++ = good; +++ = very good; HIV/AIDS = human immunodeficiency virus and showing positive results (table 7.5). acquired immune deficiency syndrome. Medical and Social Detoxification, Treatment, treatment of comorbidity and possible referral to self- Follow-Up, and Referral help groups (WHO 2008). The recent evidence for LMICs is consistent with what had previously been reported (Patel and others 2007) Self-Help and Support Groups (table 7.6). Mutual help and self-help organizations for those inter- The mhGAP recommends referral from first-level ested in reducing or ceasing drinking have been an impor- care and supervisory support by specialists for patients tant part of the social response to alcohol in many societies. with established alcohol dependence. The recommended Given that many religions forbid or discourage drinking, actions include the planning of cessation of alcohol adherence to a religious congregation or group often car- consumption and detoxification; if necessary, the treat- ries with it an expectation of mutual help to stop drinking. ment of withdrawal symptoms with diazepam; the use In many social groups in Latin America and the Caribbean, of medications to prevent relapses, such as naltrexone, joining a Protestant sect has often been a way out of socio- acamprosate, or disulfuram; and the assessment and cultural expectations of heavy drinking, particularly for 136 Mental, Neurological, and Substance Use Disorders Table 7.6 Medical and Social Detoxification, nonrelapsed subjects were sponsors helping newcomers, Treatment, Follow-Up, and Referral practiced the 12 steps more often, and reported spiritual awakening experiences more frequently (Gutiérrez and Site Main results others 2007; Gutiérrez and others 2009). Brazil (++) There were no significant differences between The WHO (2011b) makes a standard recommendation— naltrexone versus placebo during detoxification that indicates that it can be offered to the majority of (Castro and Laranjeira 2009). patients but might not be applicable to all cases—for Acamprosate was superior to a placebo in nonspecialist health care workers to be encouraged to supporting abstinence in men undergoing familiarize themselves with locally available self-help treatment (Baltieri and Guerra de Andrade 2003). groups. These groups should offer services at no cost Iran (++) Naltrexone demonstrated better results than to patients, and they should provide support for recov- placebo when used as a maintenance treatment ery and new social connections unrelated to drinking. for a 12-week period (Ahmadi and Ahmadi 2002). Relatives of patients with alcohol dependence should be India (++) Lorazepam and chlordiazepoxide showed similar encouraged to participate in appropriate self-help groups efficacy in reducing the symptoms of alcohol for families, so that they can better understand their rela- withdrawal (Kumar, Andrade, and Murthy 2009). tives’ conditions and support their recovery. Note: ++ = good. COST-EFFECTIVENESS OF INTERVENTIONS men (Butler 2006; Eber 2001). Many mutual help groups The addition of a cost component or economic dimen- that are not affiliated with particular religions or that are sion to health impact assessment introduces the oppor- entirely secular have formed in different countries (Room, tunity to identify alcohol prevention and control Jernigan, Carlini, Gmel, and others 2013; Room, Jernigan, strategies that have better or worse value for money. For Carlini, Gureje, and others 2002). The most well-known example, devoting scarce resources to interventions that and widespread is Alcoholics Anonymous, which has do not discernibly reduce ill-health caused by the con- proved adaptable to many cultural settings (Eisenbach- sumption of alcohol—as is the case for information and Stangl and Rosenqvist 1998; Mäkelä 1991). education—is a clear case of investing in interventions Affiliation with Alcoholics Anonymous and similar that are not cost-effective. At the other end of the spec- groups is not considered a form of formal treatment— trum, in contrast, imposition and enforcement of taxa- although some groups have affiliations with treatment tion policies offers an example of a highly cost-effective institutions—and incorporating mutual help groups public health intervention that costs relatively little to into a treatment system is likely to undercut their implement but reaps substantial health returns. effectiveness. The principles of voluntary mutual help The available body of economic evidence to inform organizations often do not allow random-assignment decisions around these alcohol control measures in clinical trials to test their effectiveness; consequently, LMICs remains modest and is based on a modeling not much research has been conducted on the impact approach that relies on data from higher-income settings of these groups (Ferri, Amato, and Davoli 2006; Terra for some of its inputs. Rehm and others (2006) reported and others 2007). However, survey results support on the comparative cost-effectiveness of a group of the important role of these groups; 71 percent of the interventions—enactment of legislation on drinking countries included in WHO’s Atlas on Substance Use and driving, random breath testing, taxation of alcoholic (2010) reported the presence of Alcoholics Anonymous. beverages, reduced hours of sale, and advertising bans— in East Asia and Pacific, Latin America and the Caribbean, Latin America and the Caribbean. In Mexico accord- South Asia, and Sub-Saharan Africa. Increased taxation ing to a National Household Survey (Medina-Mora and was the most cost-effective strategy, although it may have others 2012), 44 percent of persons in treatment for a regressive impact on the incidence of alcohol consump- alcohol problems reported being affiliated with self-help tion if accompanied by a rise in an already high level of groups, while only 35 percent received professional treat- unrecorded consumption. The authors found reductions ment. A study conducted in a nonprobabilistic sample of from 2 to 4 percent in the incidence of high-risk alco- 192 members of Alcoholics Anonymous found that the hol use, depending on regional drinking patterns. The level of affiliation or involvement with the organization strategy of reducing the hours of sale produced a modest was negatively related to relapse; with more involve- reduction of 1.5–3.0 percent in the incidence of high-risk ment, mean participation time was higher, and activi- drinking, together with a 1.5–4.0 percent reduction in ties related to service were more frequent. Most of the alcohol-related traffic fatalities. Alcohol Use and Alcohol Use Disorders 137 The overall conclusion from this study was that been conditioned on market deregulation, which has countries with a high prevalence of high-risk drinking diminished controls on alcohol sales. In many countries, should begin with taxation, because in such contexts drunkenness is often tolerated, awareness of the con- it appears to have the largest impact for the fewest sequences of alcohol is limited, multinational alcohol resources. In settings where high-risk drinking is less of industry interests have been politically influential, and a public health burden, other strategies that restrict the resources to fund policy measures to reduce the societal supply or promotion of alcoholic beverages appear to burden are scarce. be promising and relatively cost-effective mechanisms, In settings in which alcohol use is well established, although there is a clear need for greater empirical sup- prohibition has not proved to be an effective way to port of their efficacy. In Mexico, a combination of inter- curb the problem. The most promising alternatives are ventions yielded the best results, with higher taxation (by measures that increase the cost of alcoholic beverages 50 percent) ranked first (Medina-Mora and others 2010). and reduce the availability, accompanied by efforts to Tax increases were also the measure recommended in reduce unrecorded alcohol. Public health campaigns India (Mahal 2000). Banning advertising, in conjunction may be needed to increase awareness of the seriousness with taxation and restrictions on availability, is consid- of alcohol problems in society and build support for ered the best combination of measures (WHO 2014b). intervention measures. In terms of individual-level measures, trial-based economic evaluations have been conducted in HICs, Measures to Control Price the results of which have been used to model expected • Market regulation, prevention, and treatment have costs and health gains in LMICs (Chisholm and others been identified as strategies of choice for diminishing 2004; Rehm and others 2006). Although found to be the alcohol-related harm. most costly intervention to implement, brief interven- • Price discounts can increase consumption. Although tions also lead to a large health gain in the population research on the policy impact is scarce, evidence from as a result of an estimated 13–34 percent reduction in HICs supports the use of minimum prices for a stan- consumption among high-risk drinkers, making it a dard unit of alcohol as one of the most effective ways relatively cost-effective measure. to reduce alcohol-related problems. The relative cost-effectiveness of these alcohol • Tax increases have proven to be cost-effective, inde- control and prevention measures is further discussed pendent of the level of income, even in countries with and reviewed in chapter 12 in this volume (Levin and relatively low price elasticity. Chisholm 2015). Control of Alcohol Availability Measures to control the availability of alcohol are typi- CHALLENGES AND OPPORTUNITIES cally adopted as part of a system of alcohol control that includes licensing sellers. Enforcement of the licensing Challenges for LMICs regime is accomplished most efficiently in civil rather Alcohol is responsible for a high proportion of the global than criminal law. These measures include restricting burden of disease. Although drinkers in LMICs consume the hours, days, and locations of sale; the density of the relatively smaller quantities of alcohol compared with concentration of on-premises and retail drinking estab- drinkers in HICs, those in LMICs are more adversely lishments; and the exposure to the intoxicating effects affected. They tend to drink high quantities of alcohol of alcohol. Although these measures have been imple- per occasion, increasing the negative effects on health as mented in LMICs, only a few studies have been identi- well as increasing the rates of intentional and uninten- fied in these contexts regarding a significant reduction in tional injuries. violence; no evidence is available on the level of enforce- The challenge of implementing a health-oriented ment of regulations. alcohol policy is high, especially in LMICs, with higher burdens and fewer mitigating factors for harm, such as Unrecorded Alcohol those derived from a temperance tradition that supports Research shows that in LMICs where unrecorded alcohol control over availability and limits quantities of alcohol is widely available, the strategy of tax increases needs intake. The public health perspective has received little to be accompanied by reductions in the supply and attention in international negotiations affecting alcohol sales of unrecorded alcohol. Strategies to control the markets (Casswell and Thamarangsi 2009; Grieshaber- unregulated market can include regulating or raising the Otto, Schacter, and Sinclair 2006; Zeigler 2006). Financial cost of nonbeverage alcohol products (such as mouth- aid to LMICs from international agencies has often washes and cleaning agents) that are used as substitute 138 Mental, Neurological, and Substance Use Disorders beverages, narrowing the tax gap between beverages, within the family, yet have little impact on behavior introducing stricter controls to reduce cross-border on their own. More promising outcomes are obtained shopping, and implementing tax stamps and electronic from programs that combine this approach with alco- surveillance systems of alcohol trade sites to limit illegal hol regulations. trade and counterfeiting. Education campaigns could increase awareness of the risks associated with drinking Screening and Brief Interventions illegal alcohol. The most promising option for the con- Screening and brief interventions by trained primary trol of home and small-scale artisanal production is to health care professionals, early identification and treat- offer financial incentives to producers to ensure registra- ment of AUDs in primary health care settings, and tion and quality control. referral and supervisory support by specialists have been widely tested in LMICs and have demonstrated clinically significant effects in reducing drinking behavior and Other Opportunities related problems. Other substantial opportunities exist to reduce the bur- den of alcohol when the political will to do so exists. Treatment of Withdrawal Treatment of withdrawal symptoms—a potential Alcohol-Impaired Driving Laws life-threatening condition that can occur when a per- Impaired driving laws and strategies for reinforcing them son reduces or stops drinking after a period of heavy influence the rates of fatal and nonfatal traffic injuries by drinking—is recommended as a prerequisite to treat- modifying the drinking practices of high-risk alcohol ment of alcohol dependence. The quality of evidence users. These measures also protect others affected by the on the effectiveness of medications for the treatment behavior of drinkers. BAC limits of 0.05 g/dL can lead to ranges from low to very low. Psychosocial support has significant reductions in alcohol-related crashes, partic- been found to be more effective than no treatment. ularly if accompanied by enforcement. Motivational interviewing and motivation and moti- vation enhancement were more effective than standard Interventions to Reduce the Risk of FASD psychosocial treatment involving families and friends Although alcohol warning labels are popular, their effec- (mainly spouses), and more effective than no treatment tiveness in changing behavior is unknown. More positive or individual counseling. Referral and supervisory sup- results have been linked to treatment interventions to port by specialists for patients with established alcohol reduce alcohol intake among high-risk pregnant women. dependence are a beneficial complement, as is the involvement of patients and their families in mutual Advertising Bans help groups. Evidence suggests that packages that com- Bans on advertising, a measure not widely tested across bine interventions are more promising and have added cultures or in LMICs, have at least a modest effect on effects on curbing the alcohol problem. alcohol use. Producers and sellers tend to transfer their advertising budgets to promotions that fall outside the Interventions for Alcohol Use during Pregnancy bans. Effects may be greater in young and abstaining Women who are pregnant, breastfeeding, or planning populations. Implementation of such bans is gener- to become pregnant are recommended to avoid alcohol. ally inexpensive and can be included in the package Screening and brief interventions, detoxification and of interventions. Such packages that include banning quitting programs, and management of infants exposed advertising, accompanied by higher taxation and avail- to alcohol tailored to the needs of the pregnant women ability restrictions, constitute the best buy in reducing and the infants should be included in the services problems related to alcohol use (WHO 2014b). provided. School-and Family-Based Interventions Cost Analysis The effects of school-based interventions on the onset The available body of economic evidence to inform of drinking and drinking problems, if not accompa- decisions around alcohol control measures in LMICs, nied by effective interventions aimed at the general constituting fiscal instruments, legal limits, and reg- population, are equivocal and minimal. Evidence ulation, remains modest. It is based on a modeling shows that classroom education may increase knowl- approach that relies on data from HICs for some inputs edge and change attitudes, but it has no demonstrated (involving effect sizes, for example). Although more long-term effect on drinking behavior. Family inter- research is needed, results from this approach support ventions have proved to change communication skills further action. 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Children terized by inattention and disorganization, with or with these disorders require significant additional sup- without hyperactivity-impulsivity, causing impair- port from families and educational systems; the disorders ment of functioning (APA 2013). ADHD persists into frequently persist into adulthood (Nevo and Manassis adulthood in approximately 20 percent of individuals 2009; Polanczyk and Rohde 2007; Shaw and others 2012). (Polanczyk and Rohde 2007). These children are more likely to experience a compro- • Conduct disorder diagnosed in children under the age mised developmental trajectory, with increased need for of 18 years is characterized by a pattern of antisocial medical and disability services, as well as increased risk behaviors that violate the basic rights of others or of contact with law enforcement agencies (Fergusson, major age-appropriate societal norms. Horwood, and Lynskey 1993). • Autism is a neurodevelopmental disorder charac- terized by severe impairment in reciprocal social interactions and communication skills, as well as the Childhood Mental and Behavioral Disorders presence of restricted and stereotypical behaviors. This chapter limits the discussion to the following • Intellectual disability is a generalized disorder that five conditions: childhood anxiety disorders, attention- is characterized by significantly impaired cognitive deficit hyperactivity disorder (ADHD), conduct dis- functioning and deficits in two or more adaptive order, autism, and intellectual disability (intellectual behaviors (APA 2013). developmental disorder). • Anxiety disorders are characterized by excessive or Scope of the Chapter inappropriate fear, with associated behavioral distur- This chapter reviews interventions to reduce the prev- bances that impair functioning (APA 2013). Children alence of childhood mental and developmental disor- with anxiety disorders have clinical symptoms, ders through the prevention, reduction, or remission Corresponding author: James G. Scott, The University of Queensland Centre for Clinical Research, Queensland; Royal Brisbane and Women’s Hospital, Queensland, Australia; james.scott@health.qld.gov.au. 145 of symptoms. The effectiveness of selected interven- suffer from anxiety disorders. Anxiety disorders and tions is evidence based; these interventions have the ADHD were more common in adolescents compared potential to be delivered in low- and middle-income with children. countries (LMICs). The chapter does not discuss Most children and adolescents with mental and devel- childhood depression, because of the overlap in inter- opmental disorders were in South Asia, reflecting the high ventions with adult depression. population in this region and the reduction in mortality The chapter considers interventions in terms of deliv- of infants and young children (Murray and others 2012). ery platforms rather than specific disorders. This choice The populations of LMICs tend to have higher propor- is because of the very high comorbidity between child- tions of children and adolescents than those of high- hood mental and developmental disorders (Bakare 2012; income countries (HICs). For example, 40 percent of the Rutter 2011). In addition, risk factors for childhood population in the least developed countries is younger disorders are nonspecific and pluripotent. For example, than age 15 years, compared with 17 percent in more children who are maltreated are at higher risk of a wide developed regions (United Nations 2011). Furthermore, range of mental and developmental disorders (Benjet, population aging is occurring more slowly in LMICs, with Borges, and Medina-Mora 2010). some low-income countries predicted to have the young- est populations by 2050, given their high fertility rates (United Nations 2011). These trends mean that childhood NATURE OF CHILDHOOD MENTAL AND mental and developmental disorders will increase in sig- DEVELOPMENTAL DISORDERS nificance in LMICs. Furthermore, the continuing reduc- tions in infant mortality caused by infectious diseases Childhood mental and developmental disorders are an mean more children will reach adolescence where the emerging challenge to health care systems globally. Two prevalence of mental disorders increases and the onset of contributing factors are the increases in the proportion adult mental disorders occurs. This will challenge already of children and adolescents in the populations of LMICs, limited mental health services in these countries. which is a result of reduced mortality of children under age five years (Murray and others 2012), and the fact that the onset of many adult mental and developmental Risk Factors for Childhood Mental and disorders occurs in childhood and adolescence (Kessler Developmental Disorders and others 2007). The risk factors for childhood mental and develop- mental disorders shown in table 8.2 can be divided into lifelong and age-specific risk factors (Kieling and others Global Epidemiology and the Burden of Childhood 2011). The health of children is highly dependent on Mental and Developmental Disorders the health and well-being of their caregivers; the envi- Ascertaining the global epidemiology of mental disorders ronments in which the children live (including home is a difficult task, given the significant paucity of data for and school); and, as they transition into adolescence, many geographical regions, as well as the cultural varia- the influence of their peers. The relative importance of tions in presentation and measurement. These issues are a particular risk factor should be considered in terms of exacerbated when investigating mental disorders in chil- prevalence, strength of the association with an adverse dren, particularly in LMICs where other health concerns, outcome, and potential to reduce exposure to that risk such as infectious diseases, are priorities. The issue of data factor (Scott and others 2014). Using these criteria, paucity was highlighted in the Global Burden of Disease efforts to address maternal mental health problems and Study 2010 (GBD 2010) (Whiteford and others 2013). improve parenting skills have the greatest potential to Epidemiologically, childhood mental disorders were reduce mental and developmental disorders in children. relatively consistent across the 21 world regions defined by GBD 2010. However, these prevalence estimates were based on sparse data; some regions, such as Sub-Saharan Consequences of Childhood Mental and Africa, have no data whatsoever for some disorders or Developmental Disorders no data for specific disorders in childhood. Although The consequences of these disorders include the impact regional differences may exist, the lack of data makes during childhood and the persistence of mental ill health them difficult to ascertain. The 12-month global prev- into adult life. In childhood, the impact is broad, encom- alence of childhood mental disorders in 2010 is shown passing the individual suffering of children, as well as the in table 8.1. ADHD, conduct disorder, and autism were negative effects on their families and peers. This impact more prevalent in males; females were more likely to may include aggression toward other children and 146 Mental, Neurological, and Substance Use Disorders Table 8.1 Global Point Prevalence of Childhood Mental and Developmental Disorders by Gender and Total Number of Cases, 2010 Anxiety disorders ADHD Conduct disorder Autism Age N Males Females N Males Females N Males Females N Males Females group (1,000,000) (%) (%) (1,000,000) (%) (%) (1,000,000) (%) (%) (1,000,000) (%) (%) 5–9 5.4 0.62 1.17 5.8 1.14 0.46 16.1 3.67 1.54 1.6 0.39 0.14 years (0.55–0.70) (1.04–1.32) (1.31–1.52) (0.43–0.50) (3.24–4.18) (1.38–1.73) (0.37–0.42) (0.13–0.14) 10–14 21.8 2.54 4.77 11.9 2.95 0.92 16.2 3.73 1.57 1.6 0.39 0.13 years (2.26–2.90) (4.31–5.32) (2.75–3.17) (0.86–0.98) (3.42–4.05) (1.45–1.71) (0.37–0.41) (0.13–0.14) 15–19 32.2 3.74 7.02 8.4 2.12 0.61 15.4 3.54 1.49 1.6 0.38 0.13 years (3.33–4.16) (6.38–7.85) (1.98–2.26) (0.57–0.65) (3.17–3.96) (1.34–1.68) (0.36–0.41) (0.13–0.14) Source: Prevalence data from Whiteford and others 2013. Note: ADHD = attention-deficit hyperactivity disorder; N = number. Values in parentheses are 95 percent confidence intervals. Childhood Mental and Developmental Disorders 147 Table 8.2 Risk Factors for Mental and Developmental Disorders in Children and Adolescents Infancy and early School-age Life-long Preconception Prenatal and perinatal childhood children Adolescence Natural disasters Unwanted Inadequate prenatal care Maternal mental Family, peer, or Family, peers, or pregnancy illness school problems inadequate parenting Physical illness Inadequate spacing Complications during Early emotional Maternal mental Developmental and of children pregnancy deprivation illness behavioral problems Malnutrition Adolescent Maternal cigarette and Inadequate Bullying Maternal mental illness pregnancy alcohol use stimulation Illness or loss of Consanguinity In utero exposure to pes- Inadequate Inadequate Substance misuse caregivers ticides and other toxins parenting parenting Exposure to trauma, Birth hypoxia and other Developmental Inadequacies Early sexual activity adversity, violence, obstetric complications and behavioral of schools or or conflict problems teachers Genetic background Maternal difficulties Developmental Risk-taking behaviors adapting to pregnancy or and behavioral arrival of newborn problems Toxins Perinatal maternal Risk-taking School problems mortality behaviors Immigrant status Source: Kieling and others 2011. distraction of peers from learning. Children with mental in children. The World Health Organization (WHO) and developmental disorders are at higher risk of mental has published a modular package for governments, pol- and physical health problems in adulthood, as well as icy makers, and service planners, Child and Adolescent increased likelihood of unemployment, contact with law Mental Health Policies and Plans, to address this need enforcement agencies, and need for disability support. (WHO 2005b). The guidelines recommend attention to a broad range of areas pertaining to childhood mental and developmental disorders (box 8.1). The provision of Trends in Childhood Mental and Developmental health services for children in isolation will not prevent Disorders mental and developmental disorders or have significant GBD 2010 estimated burden across five time points benefits for children with these disorders. Instead, an (1990, 1995, 2000, 2005, and 2010) and found that the ecological approach that addresses problems in the sys- prevalence and burden of childhood mental disorders tems around children (parents, family, and school) in remained consistent between 1990 and 2010 (Erskine combination with targeted interventions for children is and others 2015). Although the rates may not have necessary to make a meaningful difference (Kieling and changed, population growth and aging have impacts on others 2011). the burden of disease attributable to mental disorders in childhood. As the population of children increases Child Protection Legislation globally, the burden of disease attributable to mental Child maltreatment is a well-established risk factor disorders in children will increase. for mental and developmental disorders in children (Benjet, Borges, and Medina-Mora 2010). Child mal- treatment is defined as any form of physical or emo- INTERVENTIONS FOR CHILDHOOD MENTAL tional ill-treatment, sexual abuse, neglect or negligent AND DEVELOPMENTAL DISORDERS treatment, or commercial or other exploitation that results in actual or potential harm to a child’s health, Population Platform Interventions survival, development, or dignity in the context of a Child and Adolescent Mental Health Policies and Plans relationship of responsibility, trust, or power (Krug and Few countries have developed national policies and others 2002). Legislation to address child maltreatment plans to address mental and developmental disorders requires the support of well-integrated systems that 148 Mental, Neurological, and Substance Use Disorders the intervention could be delivered through local Box 8.1 neighborhood groups run by mothers (Eickmann and others 2003). Areas for Action for Child and Adolescent Powell and others (2004) demonstrate that a psy- chosocial stimulation intervention could be deliv- Mental Health ered to infants in Jamaica by community health aid • Financing workers in a cluster randomized control trial of 139 • Collaboration across sectors mother-infant dyads where the infants were malnour- • Legislation and human rights ished. The weekly home visits supporting maternal play • Advocacy with children showed that infants in the intervention • Information systems group had improved overall development as well as • Research and evaluation of policies and improved hearing, speech, and hand-eye coordination. services Health aid workers received two weeks of additional • Quality improvement training to deliver the intervention, which was pro- • Organization of services vided as part of an existing home visitation program • Promotion, prevention, treatment, and for malnourished children (Powell and others 2004). rehabilitation A follow-up study 25 years later found that those • Improved access to and use of psychotropic Jamaican children who received early psychosocial medicines stimulation had, on average, 25 percent increased earn- • Human resources development and training. ings, suggesting long-term economic benefits to infants receiving this intervention (Gertler and others 2014). Source: WHO 2005b. These studies show psychosocial stimulation is an effective intervention to support cognitive, language, and motor development in young children, conferring short- and long-term benefits, although mental health increase public awareness and enable incident report- outcomes were not assessed. ing to a constituted authority with investigative and The delivery of community-based interventions interventional expertise and the ability to prosecute poses significant challenges, but the feasibility has been (Svevo-Cianci, Hart, and Rubinson 2010). Limited demonstrated in LMICs (Bauermeister and others evidence suggests that legislation to protect children 2006). Brazil, the Arab Republic of Egypt, Israel, and living outside the family home in LMICs has benefits Lebanon implemented and evaluated a comprehensive for their health and safety (Fluke and others 2012); community-based program with a package of interven- however, further research is needed to determine the tions that could be adapted to different countries and effectiveness of such legislation for children living with localities based on the following: their families of origin. • Amount of health care and school resources available • Nature and severity of the types of problems in Community Platform Interventions children Early Child Development • Preferences and cultural factors that are important Attempts have been made to develop community- and within communities. primary care–based services in LMICs. Eickmann and others (2003) delivered a community-based psychoso- Manuals were developed that enabled non-mental cial stimulation intervention to mothers in a study of health professionals in areas with limited resources to 156 infants (age 12 months) in four towns in Brazil. deliver the interventions. The manuals consisted of The intervention consisted of 14 contacts (three work- education, parenting skills training, child training, and shops and 11 home visits) where mothers were taught cognitive and behavioral therapy. These were adapted for the importance of play for children’s development, how local communities with attention to terminology, mod- to make toys from disposable household items, and ifications to reduce stigma, and emphasis on culturally how to play and positively interact with their children. acceptable parenting skills. The feedback received from Children of mothers who received the intervention had these sites indicates that the interventions were useful significantly improved cognitive and motor develop- in helping children with internalizing and externalizing ment; the greatest effects were observed in infants whose problems (Bauermeister and others 2006). Strategies development was mildly delayed. The authors proposed to improve access to community-based interventions Childhood Mental and Developmental Disorders 149 require investments in gatekeepers, such as parents, (Baker-Henningham and others 2012). This study teachers, and general practitioners. Easy-to-read manuals demonstrates that school-based interventions in a and guides with culturally adapted strategies for the middle-income country are effective and feasible in management of childhood mental disorders through reducing behavioral problems in young children. nonspecialist primary care can be useful resources for Bullying or peer victimization is a specific form practitioners seeking to develop services in such settings of aggression defined as “a form of aggression in (Eapen, Graham, and Srinath 2012). which one or more children repeatedly and intention- Most preventive interventions implemented in early ally intimidate, harass, or physically harm a victim” childhood in LMICs target child development gen- (Vreeman and Carroll 2007). The long-term impacts of erally, rather than child mental health specifically. bullying behavior are serious; children who are victims, However, increasing evidence shows that some of these bullies, or both have elevated rates of psychiatric disor- early interventions can benefit the mental health of ders in childhood and early adulthood (Copeland and children, with benefits maintained into adolescence others 2013). Accordingly, the prevention of peer vic- and adulthood. In Jamaica, an early stimulation pro- timization in schools is an important strategy to reduce gram for very undernourished children, which involved the occurrence of mental disorders and other adverse home visits over two years, reduced anxiety, depression, consequences in children and adults. and attention deficit disorder, and enhanced self- Different approaches to reducing bullying behavior esteem at ages 17–18 years (Walker and others 2010). have been assessed in the literature. In one system- In Mauritius, two years of high-quality preschool, from atic review, Vreeman and Carroll (2007) grouped the age three years, reduced conduct disorder and schizo- interventions into three main types: curriculum inter- typal symptoms at age 17 years and criminal offenses ventions, whole-of-school approaches, and social and at age 23 years (Raine and others 2003). These benefits behavioral skills training. Whole-of-school approaches were greatest for children who were undernourished at have been found to be effective; these approaches use age three years. Such interventions can be integrated a multidisciplinary approach that includes combina- with community-based maternal child health pro- tions of school rules and sanctions, classroom cur- grams and should be prioritized in LMICs (Kieling and riculum, teacher training, individual counseling, and others 2011). conflict resolution training. In a meta-analysis, Ttofi and Farrington (2011) found that school-based anti-bullying School-Based Interventions programs can reduce bullying by about 20 percent, with Schools have a profound influence on children, families, greater effects observed in interventions that adopt more and communities. School-based mental health ser- of a whole-of-school approach. However, very few, if any, vices also have the potential to bridge the gap between evaluations of interventions to prevent bullying have need and utilization by reaching children who would been conducted in LMICs. otherwise not have access to these services. These set- Further research is required to demonstrate the tings could provide an ideal environment in which effectiveness of school-based interventions supporting programs for child mental health can be integrated children with autism and intellectual disability. in a cost-effective, culturally acceptable, and nonstig- matizing manner (Patel, Aronson, and Divan 2013). Voluntary Sector Programs However, the evidence for school-based interventions Agencies in the voluntary sector (those that are nongov- for childhood mental and developmental problems in ernment and not for-profit) have traditionally played an LMICs is limited (Kieling and others 2011; Maulik and important role in raising awareness of the issues faced Darmstadt 2007). by children with mental health difficulties and their In Jamaica, Baker-Henningham and others families, as well as in reducing the associated stigma. In (2012) conducted a cluster randomized control trial some countries, the voluntary sector provides the bulk of 225 children (ages 3–6 years) with high levels of child mental health services. However, the evidence of emotional and behavioral problems, attending base for such interventions is poor, largely because of 24 community preschool centers. The study exam- the absence of research support for program evaluation. ined the effectiveness of teacher training in “The The magnitude of mental health problems affecting Incredible Years,” a children’s mental health program. children and the absence of policies to guide service The intervention led to significant reductions in con- development are significant barriers to coordinated duct problems (effect size [ES] = 0.42) and increased service provision and evaluation of voluntary sector friendship skills (ES = 0.74). School attendance and programs for children in LMICs (Omigbodun 2008; parent-reported behavior at home also improved Patel and Thara 2003). 150 Mental, Neurological, and Substance Use Disorders Health Care Platform Interventions any history of seizures; one assesses vision; and one Screening and Community Rehabilitation for assesses hearing. The items require a dichotomous Developmental Disorders response of yes-no and ask about the skills that children Providing early interventions to children with devel- will acquire in any culture. They ask parents to compare opmental disorders may optimize their developmental their children to other children in their community outcomes (Sonnander 2000). Screening is necessary to (Belmont 1986; Zaman and others 1990). The TQ was identify children in need of these resource-intensive included as a disability module in the third round of interventions. Screening instruments for LMICs need the United Nations Children’s Fund Multiple Indicator to be culturally acceptable and have sound psycho- Cluster Survey, and administered to almost 200,000 metric properties that have been validated in the local children across 18 countries (Gottlieb and others 2009). context (Robertson and others 2012). Instruments The TQ is a sensitive tool that identifies 80–100 percent developed for screening children for developmental of children with developmental disorders; however, disorders in HICs (such as Denver II) may not be it has a low specificity, necessitating a second stage to appropriate (Gladstone and others 2008). For exam- examine those children who screen positive (Durkin ple, items assessing whether a child can cut using and others 1994). scissors or catch a bouncing ball may be inappropriate Administration of the ACCESS portfolio provides if these resources are unavailable in the community or screening of children with developmental disorders, if parents do not model or encourage these activities. as well as simple advice to parents. Community health A systematic review identified instruments that have workers (CHWs) in Sri Lanka and Uganda used the been used for the developmental screening of young ACCESS portfolio to assess children younger than age children in LMICs (Robertson and others 2012). Two three years whose mothers had expressed concerns. The of the screening tools identified as useful were the Ten CHWs’ assessments of delay had an 82 percent accu- Questions (TQ) screen (Belmont 1986; Zaman and racy in children older than age two years, compared others 1990) and the ACCESS portfolio (Wirz and with those identified by medical or allied health staff, others 2005). although the sensitivity and specificity of the instru- The TQ screen (box 8.2) is a brief questionnaire ment were not measured. The ACCESS portfolio raised administered to parents of children ages two to nine awareness of developmental disorders in communities, years. Five questions assess cognitive ability; two ques- and CHWs and parents reported it to be helpful (Wirz tions assess movement ability; one question addresses and others 2005). Box 8.2 Ten Questions Screen 1. Compared with other children, did the child have 8. Does the child speak at all (can he/she make any serious delay in sitting, standing, or walking? himself/herself understood in words, can he/she 2. Compared with other children, does the child say any recognizable words)? have difficulty seeing, either in the daytime or 9. For children ages three to nine years, ask: Is the night? child’s speech in any way different from normal 3. Does the child appear to have difficulty hearing? (not clear enough to be understood by people 4. When you tell the child to do something, does other than his/her immediate family)? he/she seem to understand what you are saying? For children age two years, ask: Can he/she name 5. Does the child have difficulty in walking or mov- at least one object (for example, an animal, a toy, ing his/her arms, or does he/she have weakness a cup, a spoon)? and/or stiffness in the arms or legs? 10. Compared with other children of his/her age, 6. Does the child sometimes have fits, become rigid, does the child appear in any way mentally or lose consciousness? backward, dull, or slow? 7. Does the child learn to do things like other chil- dren his/her age? Source: Zaman and others 1990. Childhood Mental and Developmental Disorders 151 Two significant issues arise following the identifi- Sanders 2012). However, eight studies examined interven- cation of children with developmental disorders. The tions to prevent or reduce emotional and behavioral prob- first involves the stigma associated with these diagnoses lems in children. The following outcomes were assessed: in some countries and cultures. The second is the lim- ited evidence for the effectiveness of community-based • Infant attachment (Cooper and others 2009) rehabilitation for children with intellectual disabilities • Maternal understanding and attitude about child and autism in LMICs. These issues do not necessarily development (Jin and others 2007; Klein and Rye indicate that interventions are ineffective, but rather that 2004; Rahman and others 2009) further evaluation is required (Hastings, Robertson, and • Mother-child interaction (Klein and Rye 2004; Yasamy 2012; Robertson and others 2012). Wendland-Carro, Piccinini, and Millar 1999) • Child abuse (Aracena and others 2009; Oveisi and Parenting Skills Training others 2010) Parenting skills training aims to enhance or support the • Reductions in child behavioral problems (Fayyad and parental role through education and training, thereby others 2010). improving emotional and behavioral outcomes for chil- dren. A meta-analysis identified four components of The mean effect size of the parenting skills training parenting skills training that were particularly effective. across the eight studies was large (Cohen’s d = 0.81) Increasing positive parent-child interactions, teaching (Mejia, Calam, and Sanders 2012); benefits persisted parents how to communicate emotionally with their in the follow-up studies, which were as long as 18 children, teaching parents the use of time out as a means months in a study in South Africa (Cooper and others of discipline, and supporting parents to consistently 2009) and six years in a study in Ethiopia (Klein and respond to their children’s behaviors had the largest Rye 2004). Thus, emerging evidence from available effects on reducing externalizing behaviors in children research suggests parenting skills training is a feasible (Kaminski and others 2008). and effective intervention in LMICs. The extensive Several systematic reviews have demonstrated the research base available from HICs requires integration effectiveness of parenting skills training in reduc- with knowledge acquired from studies conducted in ing internalizing and externalizing problems in chil- LMICs for the development of culturally appropriate dren (Furlong and others 2013; Kaminski and others parenting skills training. 2008), as well as in reducing the risk of unintentional childhood injuries (Kendrick and others 2007) and Maternal Mental Health Interventions improving the mental health of parents (Barlow and Poor maternal mental health is a risk factor for children’s others 2014). Childhood disruptive and externaliz- physical, cognitive, and socioemotional development ing behaviors may persist into adolescence, affect- (Deave and others 2008; Feldman and others 2009; ing peers, schools, and communities (Fergusson, Glasheen, Richardson, and Fabio 2010; Grace, Evindar, Horwood, and Lynskey 1994). Furthermore, although and Stewart 2003; Grigoriadis and others 2013; Grote many externalizing behaviors diminish as individuals and others 2010; Hamadani and others 2012; Wachs, mature through adolescence, life course persistence Black, and Engle 2009; Wan and others 2007); the impact of antisocial behaviors is more likely in those with continues into adolescence and adulthood (Murray and childhood-onset conduct problems (Moffitt and others others 2011; Pearson and others 2013). Interventions 2002). A meta-analysis of group-based parenting skills that target maternal mental health problems, especially training for parents of children with conduct problems in the perinatal period and early infancy, are important showed moderate effect sizes with a standardized mean for child mental health and need to be incorporated into difference in conduct problems of –0.53 (95 percent primary care. confidence interval [CI]: –0.72 to –0.34) as assessed by Perinatal mental disorders can be divided into com- parents (Furlong and others 2013). Therefore, parent- mon mental disorders (including depression and anxiety ing skills interventions can reduce or prevent the onset disorders) and severe mental disorders (schizophrenia of childhood mental disorders and subsequent adverse and bipolar disorder). Two meta-analyses have reported health and social outcomes. that the prevalence of common mental disorders in The evidence for the effectiveness of parenting skills women in LMICs is between 15.6 percent during preg- training comes from studies conducted in HICs (Furlong nancy and 19.8 percent postpartum (Fisher and others and others 2013). A systematic review of parenting inter- 2012; Parsons and others 2012). Maternal depression is ventions in LMICs reported that most studies examined the most prevalent condition—and has the largest pub- educational or physical outcomes (Mejia, Calam, and lic health impact (Rahman, Surkan, and others 2013). 152 Mental, Neurological, and Substance Use Disorders A recent systematic review identified 16 longitudinal trial of 230 women. The intervention consisted of group studies of adolescent mental and developmental health education about illness and symptoms, problem-solving outcomes of children of mothers who had postnatal strategies for mothers, and structured pharmacotherapy depression. Increased risk of cognitive delays in the chil- when required, delivered through existing local primary dren was the most consistent finding, with some studies care clinics. Compared with those who received treat- also reporting that children of mothers with postnatal ment as usual, mothers with depression had significant depression had increased risk of internalizing and exter- improvements. This study demonstrates the efficacy and nalizing symptoms and increased general psychopathol- feasibility of delivering care to mothers with postnatal ogy (Sanger and others 2015). Accordingly, treatment of depression in an LMIC (Rojas and others 2007). maternal mental health problems can reduce suffering Participatory women’s groups are also a viable model in the mother while potentially preventing mental and of intervention for postnatal depression. Improvements developmental disorders in the children. in maternal and infant health were achieved in a study of Postnatal depression is the condition for which inter- 19,030 births in rural India through monthly participa- ventions are most amenable to integration into primary tory groups facilitated by peers. The study involved the care and maternal and child health platforms (Rahman, identification of maternal and neonatal health problems, Surkan, and others 2013). Such integration requires identification of solutions, and implementation and task-shifting strategies, supported by the development evaluation of strategies in partnership with local health of training curricula and treatment packages that bun- services (Tripathy and others 2010). This study demon- dle skills that are logically grouped together for content, strates the feasibility and effectiveness of participatory training, and operational use (Patel and others 2013). women’s groups in reducing postnatal depression in a These interventions also require a change in the very poorly resourced region of India. approach of mental health specialists, as well as health Much of the research on psychological and psychoso- policy and planning specialists—a shift of focus from cial interventions for maternal depression has been con- a model that is specialist and center based to a model ducted in HICs (Sockol, Epperson, and Barber 2011). that is primary care and community based. Integrated Substantial evidence indicates that such interventions treatment programs, in which health and social care pro- are effective in reducing depressive symptoms within the viders are supported to manage common mental health first year postpartum (relative risk = 0.70, 95 percent CI: problems, offer a chance to treat the whole person. This 0.60 to 0.81) (Dennis and Hodnett 2007). Over the past approach is more patient centered and is often more decade, evidence of the effectiveness of interventions led effective than one in which mental, physical, and repro- by non-mental health specialists (for example, by nurses, ductive health problems are addressed separately with- health visitors, or midwives) has increased (Crockett out effective communication among providers (Patel and others 2008; Lumley and others 2006; MacArthur and others 2013). and others 2003; Morrell and others 2009; Roman and Maternal and child health workers are well-positioned others 2009). to adopt comprehensive approaches to care, which is par- In LMICs, the public health importance of mater- ticularly important for children because their psychoso- nal mental health has led to increased research on cial well-being is closely linked to the mental health of interventions. A review and meta-analysis identified 13 their parents and the quality of their family and school trials that included 20,092 participants (Rahman, Fisher, environments. Maternal and child health workers have and others 2013). In all these studies, the intervention was knowledge of community resources and health, social, delivered by supervised, nonspecialist health and com- and education services, and they can better respond to munity workers; in many of the studies, the intervention the specific needs of local communities. In Pakistan, the was integrated into a primary care platform. Compared Canadian “Learning through Play” program was adapted with routine care, the evidence suggests significant ben- and taught through one-day workshops to women in efits for mothers and children from the interventions the Lady Health Workers program, members of the local tested. The pooled effect size for maternal depression was community who deliver preventive maternal and child 0.38 (95 percent CI: –0.56 to –0.21). Where assessed, the health care. A cluster randomized trial demonstrated benefits to children included improved mother-infant that an evidence-based program for maternal mental interaction, better cognitive development, reduced health and child development can be delivered through diarrheal episodes, and increased rates of immunization. existing local health workers in an LMIC (Rahman, Surkan, and others 2013). Cognitive Behavioral Therapy In Chile, a multicomponent intervention for post- Cognitive behavioral therapy (CBT) is a psychologi- natal depression was evaluated in a randomized control cal intervention used for the management of anxiety Childhood Mental and Developmental Disorders 153 disorders in children. The components of CBT for chil- of stimulant medications is increasing in HICs dren consist of cognitive interventions and behavioral (Hollingworth and others 2011; McCarthy and others strategies. The cognitive interventions teach children to 2012), but no studies have examined whether these recognize their anxious feelings and the somatic expe- trends exist in LMICs. The wide recognition in HICs riences that accompany anxiety (for example, breath- of the problems of stimulant medication diversion and lessness and palpitations), identify the anxious thoughts misuse has resulted in recommendations for increased that are associated with the anxious feelings, develop monitoring and regulations (Kaye and Darke 2012). alternative thoughts (for example, positive self-talk) Therefore, although stimulant medications are very and other coping strategies, and evaluate the differences effective treatments for ADHD, the potential difficul- in their emotions after using the coping strategies. The ties with obtaining comprehensive assessments of the behavioral interventions include relaxation training, children to ensure accurate diagnosis and the high like- modeling behaviors, and graded exposure to anxiety- lihood of diversion and misuse in the absence of regula- provoking stimuli. tory systems limit the feasibility of the widespread use of A meta-analysis of 41 studies examined the effec- stimulant medications in LMICs. tiveness of CBT compared with waitlist control, treat- ment as usual, and other interventions (James and Specialist Health Care others 2013). Compared with waitlist controls, CBT Medications for Conduct Disorder. Parenting inter- had a large effect on reducing anxiety diagnoses and ventions are the best treatments for younger chil- symptoms, with a standarized mean difference of –0.98 dren with disruptive behavioral disorders, such as (95 percent CI: –1.21 to –0.74). However, these studies oppositional defiant disorder and conduct disorder. were conducted in outpatient clinics in HICs; none of However, the use of pharmacotherapy can assist in the included studies were from LMICs. the treatment of adolescents with conduct disorder. The evidence for the effectiveness of CBT in LMICs Recent evidence has suggested that the use of phar- is very limited; two studies evaluate the effectiveness of macologic agents—in particular, second-generation this intervention. In Zambia, local lay counselors deliv- antipsychotics—is increasing (Pringsheim and ered trauma-focused CBT to the families of 58 children Gorman 2012) in children and adolescents with con- and adolescents between the ages of 5 and 18 years who duct disorder. had moderate to severe trauma symptoms. The inter- Although the use of such agents is increasing, the evi- vention was provided to the families of the children and dence base is not necessarily strong. Reasonably strong achieved significant reductions in the severity of trauma evidence supports the use, particularly in the short term, symptoms, as well as the feelings of shame. Although of second-generation antipsychotics, especially risperi- there was no control group, this study demonstrates the done, in young people with borderline intelligence quo- potential feasibility of delivering trauma-focused CBT tients (IQs) (Duhig, Saha, and Scott 2013). However, the in LMICs (Murray, Dorsey, and others 2013; Murray, evidence in young people with a normal IQ is not strong. Familiar, and others 2013). Other agents have also been evaluated in such children, In a study in Brazil, clinical psychologists delivered including stimulants and lithium (Ipser and Stein 2007). 14 sessions of group-based CBT, with two concurrent Psychopharmacological therapy in young people with parental sessions, to 28 children ages 10–13 years who conduct disorder needs to be carefully monitored and were suffering from anxiety disorders. Twenty children only introduced within the setting of specialist care (71 percent) completed the treatment; there was a (Ipser and Stein 2007). Its routine use, particularly in reduction in symptoms, with a moderate to large effect LMICs, is not recommended. size (Cohen’s d between 0.59 and 2.06), depending on the outcome measure used (De Souza and others 2013). Psychosocial Treatments for Conduct Disorder. These studies provide preliminary evidence of the feasi- Psychosocial treatments have been evaluated for children bility of CBT-based interventions for anxiety disorders and adolescents with conduct disorder and other disrup- in LMICs; however, further research is needed. tive behaviors, including cognitive behavioral interven- tion (CBI), problem-solving skills therapy (PSST), and Medications for ADHD multisystem therapy. Pharmacotherapy has the strongest evidence for reduc- ing behavioral problems and improving the atten- • Cognitive behavioral intervention. The goal of CBI is to tion and educational performance of children with train children in altering their dysfunctional (aggres- ADHD (Benner-Davis and Heaton 2007; Greenhill and sive) cognitive processes. Generally, such interven- others 2002; Prasad and others 2013). The dispensing tions have been found to be effective in children 154 Mental, Neurological, and Substance Use Disorders with disruptive behaviors, with effect sizes observed COST-EFFECTIVENESS ANALYSES of approximately 0.67 (Sukhodolsky, Kassinove, and Gorman 2004). A meta-analysis of CBI and parenting The evidence base for the cost-effectiveness of interven- interventions and CBI for the treatment of youth tions targeting children and adolescents is considerably with antisocial behavior problems (a common sequa- more modest than that for adults. In a systematic review lae of conduct disorder) found that the effect size was of the literature that included studies published up to 0.47 for parenting interventions and 0.35 for CBI 2009, Kilian and others (2010) found 19 studies of the (McCart and others 2006). This review concluded cost-effectiveness of psychiatric interventions targeting that parent training appeared to have greater impacts children and adolescents. Few studies use a cost-utility on younger children and CBI was more effective for analysis framework, whereby outcomes are expressed as adolescents. generic indices combining mortality and morbidity; a • Problem-solving skills therapy. PSST is an common example of such an outcome is quality-adjusted individual-based intervention for children and ado- life years (QALYs). The advantage of cost-utility analysis lescents that focuses on changing the way children is that value-for-money judgments can be made, since interact with the significant others in their lives. The thresholds of good value can be specified for QALYs in existing evaluations of this type of therapy were con- different health care settings (Drummond and others ducted in the 1990s (Kazdin, Siegel, and Bass 1992). 2005). Moreover, interventions can be compared within These studies have shown the therapy to be largely and across different disorder categories. efficacious and incrementally supportive of the thera- Studies of pharmacological interventions for ADHD peutic effects of parent training (Handwerk and others have largely found such interventions to be cost-ef- 2012). PSST has also been found to be effective as an fective (King and others 2006), with existing studies adjunctive treatment for conduct disorder. The evi- finding that such interventions fall below commonly dence suggests that PSST can complement parenting accepted thresholds of value for money in HICs (such interventions and increase the effectiveness of parent- as £30,000/QALY1). Studies that have evaluated uncer- ing interventions incrementally (Handwerk and others tainty around the point estimates have found such 2012). The evidence for adapting PSST to various cul- conclusions to be robust (Donnelly and others 2004). tures is limited, and further research is required before Evaluations of behavioral interventions find such inter- this intervention can be recommended in LMICs. ventions to be cost-effective; for example, Dretzke and • Multisystem therapy. Multisystem therapy is a com- others (2005) find that parenting interventions for prehensive intervention targeting adolescents with conduct disorder are cost-effective. However, sensitivity disruptive behaviors. It is a highly intensive ther- testing around this estimate shows that the results could apy based on the use of different types of thera- change dramatically depending on model assumptions. pies deemed appropriate by individual therapists. Mihalopoulos and others (2007) find that modest The existing evaluations of this therapy, including improvements in the symptoms of conduct disorder meta-analyses, have demonstrated its efficacy, par- can be associated with considerable cost-savings that ticularly in adolescents with more serious delin- outweigh the cost of implementing the parenting inter- quency tendencies (Curtis, Ronan, and Borduin vention in an Australian setting. No identified studies 2004). However, the therapy’s highly intensive have evaluated the cost-effectiveness of interventions nature may render it unsuitable as an intervention in LMICs. in LMICs. In conclusion, the evidence base of the cost-effectiveness of interventions targeting children and adolescents with Handwerk and others (2012) provide an excellent mental disorders is still in its infancy. The reasons for summary of the literature on interventions target- this include the limitations of the use of generic outcome ing conduct disorders. The overall recommendations indexes, such as QALYs, in children with mental disor- include parent training, particularly for parents of ders, as well as the difficulties in assessing costs. Future younger children, with the choice of intervention for- research to fill this evidence gap is urgently needed. mat largely a matter of personal and health system preference. The evidence base for CBI is not as extensive as that for parenting interventions; the effect sizes appear CONCLUSIONS to be small to modest. Notably, the augmentation of par- Childhood mental and developmental disorders globally enting interventions with CBI appears to be particularly account for a significant health and societal burden. promising. Furthermore, CBI interventions seem to have The evidence base for interventions to prevent and treat more efficacy in adolescents. mental and developmental disorders in LMICs is limited. Childhood Mental and Developmental Disorders 155 Table 8.3 Summary of Recommendations for Interventions for Childhood Mental and Developmental Disorders Intervention Childhood disorders/problems Supporting evidence in LMICs Perinatal interventions, for example, Intellectual disability Existing screening is in more than 30 coun- screening for congenital hypothyroidism tries, including LMICs. Population-based interventions targeting Intellectual disability and other delays One case control study demonstrates maternal alcohol use associated with fetal alcohol spectrum effectiveness and feasibility (Chersich and disorder others 2012). Psychosocial stimulation of infants Developmental delays in infants RCTs demonstrate excellent effectiveness and young children younger than 3 years and feasibility. School-based life skills training to build Behavioral problems in pre-school One RCT in Jamaica shows effectiveness and social and emotional competencies in children (ages 3 to 6 years) feasibility. children and adolescents Screening with TQ or the ACCESS portfolio Developmental disorders in children Feasibility demonstrated may be useful in and adolescents assessing the needs of a community. Parenting skills training Emotional and behavioral problems; Meta-analysis of multiple studies developmental disorders demonstrates effectiveness and feasibility for reducing emotional and behavioral problems with a large effect size (0.81). Maternal mental health interventions Emotional and behavioral problems Meta-analysis of multiple studies and developmental delays in children demonstrates effectiveness and feasibility with a moderate effect size (0.38). Cognitive and behavioral therapy Anxiety, post-traumatic stress disorder Evidence is limited to two small RCTs. Note: LMICs = low- and middle-income countries; RCT = randomized control trial; TQ = Ten Questions screen. Future implementation of programs to address childhood interventions to protect children is urgently required mental and developmental disorders in LMICs should be in LMICs. Reducing bullying in schools may prevent evaluated. Other evidence-based key recommendations mental disorders in childhood and later in life; however, for interventions are summarized in table 8.3. there are no data to show effective programs in LMICs. As the evidence presented in this chapter indicates, The widespread implementation and evaluation of key interventions that have the potential to reduce parenting skills training, including psychosocial stim- mental and developmental disorders in childhood are ulation and maternal mental health interventions, is parenting skills training that includes psychosocial stim- recommended in all countries to achieve a meaningful ulation, teacher training with “The Incredible Years” reduction in the global prevalence and burden of child- program, and maternal mental health interventions. The hood mental and developmental disorders. evidence suggests that these can be feasibly delivered in LMICs, and that they have a strong efficacy in HICs. CBT for anxiety disorders has a strong evidence base in NOTES HICs, but much more work is needed to demonstrate World Bank Income Classifications as of July 2014 are as the feasible delivery of this intervention in LMICs. follows, based on estimates of gross national income (GNI) Pharmacotherapy requires specialist care and assessment per capita for 2014: that limits use in LMICs. The screening of children for developmental dis- • Low-income countries (LICs) = US$1,045 or less orders is possible in LMICs; however, the evidence • Middle-income countries (MICs) are subdivided: for intervening once autism or intellectual disabil- a) lower-middle-income = US$1,046 to US$4,125 ity has been identified is limited. Similarly, child protec- b) upper-middle-income = US$4,126 to US$12,745 tion and reduction of bullying in schools are important • High-income countries (HICs) = US$12,746 or more. preventive strategies for childhood mental disorders. 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International Journal of Rehabilitation Research 28: Walker, S. P., S. M. Chang, N. Younger, and S. M. 293–302. Grantham-McGregor. 2010. “The Effect of Psychosocial Zaman, S. S., N. Z. Khan, S. Islam, S. Banu, S. Dixit, and others. Stimulation on Cognition and Behaviour at 6 Years in a 1990. “Validity of the ‘Ten Questions’ for Screening Serious Cohort of Term, Low-Birthweight Jamaican Children.” Childhood Disability: Results from Urban Bangladesh.” Developmental Medicine and Child Neurology 52: e148–54. International Journal of Epidemiology 19: 613–20. Childhood Mental and Developmental Disorders 161 Chapter 9 Suicide Lakshmi Vijayakumar, Michael R. Phillips, Morton M. Silverman, David Gunnell, and Vladimir Carli INTRODUCTION the WHO mortality database to generate estimates of cause-specific mortality globally—the Global Health An estimated 804,000 deaths by suicide occurred glob- Estimates (GHE). However, many countries, particu- ally in 2012 (WHO 2014a). Of these, 75.5 percent larly LMICs, do not have high-quality vital registration were in low- and middle-income countries (LMICs), systems; 78 of the 140 LMICs do not have any vital which have limited resources to address the issue. The registration system at all. Most estimates of suicide reasons for suicides are multifactorial, but suicides are rates in LMICs are based on subnational reports, which preventable. may not be nationally representative, and modeling Suicide is operationally defined for the purpose of this algorithms. The number and quality of the subnational chapter as the deliberate act of killing oneself. Suicide studies have increased and these modeling algorithms attempt describes any nonfatal suicidal behavior, such as have improved, but serious questions remain about intentional self-inflicted poisoning, injury, or self-harm. the accuracy of the estimated suicide rates. This prob- The inclusion of deliberate self-harm (DSH) within the lem is most evident in the WHO Africa and Eastern definition of suicide attempt is potentially controversial, Mediterranean regions, where 98 and 75 percent, because it includes some acts carried out without sui- respectively, of estimated suicides occur in countries cidal intent. Nevertheless, suicide intent can be difficult with no vital registration system. to ascertain. Accordingly, the approach in this chapter The GHE estimates (WHO 2014b) provide the best follows that used by the World Health Organization available estimates of the number and demographic (WHO) and classifies DSH under suicide attempt. characteristics of suicides in 2012 for 197 countries and territories. The WHO report provides global and regional estimates and country-specific results for 172 EPIDEMIOLOGY OF SUICIDE IN LMICs of the 194 member states that have populations greater The WHO report on suicide (WHO 2014a) provides than 300,000. The estimates and results can help to the most up-to-date estimates of the global burden inform the discussions of decision makers in LMICs of suicide, but it is important to keep in mind the interested in reducing suicides, but independent assess- limitations of these data. The report uses vital regis- ments of the accuracy and reliability of the estimates in tration data provided by countries and recorded in specific jurisdictions are needed. Corresponding author: Lakshmi Vijayakumar, Sneha, Voluntary Health Services, Chennai, India; Center for Youth Mental Health, University of Melbourne, Australia; lakshmi@vijayakumars.com. 163 Suicide Mortality The mean age of suicide in HICs is higher than in WHO reports that 804,000 suicide deaths occurred LMICs, 50.4 versus 42.0 years, respectively, a difference globally in 2012. The demographic characteristics and largely accounted for by the difference in the median regional distribution of suicides, and the changes in sui- ages of the populations. Despite the higher rates of cide rates between 2000 and 2012, are shown in table 9.1 suicide in the elderly, for males and females in LMICs, and figure 9.1. Substantial differences exist in the rates over 63 percent of all suicides occur in individuals ages and characteristics of suicide between LMICs and 15–49 years. high-income countries (HICs) as well as among LMICs in the six WHO regions. To facilitate the comparison of Relative Importance of Suicide as a Cause of Death rates between regions and countries, the rates reported Suicide accounted for 1.7 percent of all deaths in HICs here per 100,000 population are all standardized to the and 1.4 percent in LMICs in 2012, making suicide the age distribution of the global population in 2012. 11th most important cause of death in HICs and the 17th most important cause in LMICs. Among ages 15–29 years in LMICs, suicide accounts for 7.9 percent Overall Suicide Rates of all deaths and is the third most important cause of The 2012 age-adjusted suicide rate in HICs (12.7) was death; among persons ages 30–49 years, suicide accounts slightly higher than that in LMICs (11.2); over 75 percent for 3.4 percent of all deaths and is the seventh most of all global suicides occur in LMICs, given their larger important cause of death. Another measure of the public proportion of the global population. Among LMICs, the heath importance of suicide is that it is the most impor- region-specific suicide rate in the six regions varies over tant type of intentional violent death (which includes a threefold range (from 6.1 to 17.7); the country-specific suicides, murders, and war-related deaths): in LMICs, rate varies over a 100-fold range, from 0.44 in the Syrian suicide accounts for 44 percent of all violent deaths in Arab Republic to 44.2 in Guyana. males and 70 percent of all violent deaths in females. Suicide Rates by Gender Changes in Suicide Rates, 2000–12 The suicide rate among males in HICs is higher than The WHO report highlights the volatility of suicide among males in LMICs, 19.9 versus 13.7, respectively; rates. From 2000 to 2012, the absolute number of sui- the suicide rate among females in HICs is lower than cides in LMICs dropped by 11 percent, and the suicide among females in LMICs (5.7 versus 8.7). This results rate dropped by 30 percent. in a substantially lower male-to-female ratio of suicide As shown in figure 9.1, among LMICs in the six rates in LMICs (1.6) than HICs (3.5). Suicides among regions, the percent change in suicide rates ranged females account for 43 percent of all suicides in LMICs, from a drop of 58 percent in the Western Pacific, largely and 22 percent in HICs. However, the comparison of all driven by the drop in rates in China (Wang, Chan, and HICs to all LMICs obscures region-specific differences. Yip 2014), to an increase of 1.5 percent in the Africa For example, the male-to-female ratios in LMICs in region. In 54 (44 percent) of the 123 LMICs with popu- Europe and the Americas are higher (not lower) than lations greater than 300,000, the rate increased by more in HICs. than 10 percent; in 22 countries (18 percent), the rate decreased by more than 10 percent. Given these rapid Suicide Rates by Age changes in suicide rates for the majority of LMICs, Figure 9.2 shows the gender by age pattern of suicide policies and programs to reduce suicides need to be for several regions in 2012. All regions have low rates based on recent information about suicide in the target in those younger than age 15 years and relatively high community. The use of before versus after changes in rates in those over age 70 years. The suicide rate by suicide rates is not a reliable method for assessing the gender between ages 15 and 69 years varies by region. effectiveness of prevention initiatives. In most regions, rates among males are much higher than among females in all age groups other than the very young; however, in the Eastern Mediterranean and Suicide Attempts Western Pacific regions, male and female suicide rates Prior suicide attempt is one of the strongest predictors are comparable in all age groups. The Africa region has of subsequent death by suicide, so monitoring the rate, a peak in suicide rates among young men, which is not demographic pattern, and methods of suicide attempts is seen in other regions, while the South-East Asia region a key component of suicide prevention efforts. However, has a peak in suicide rates among young women that is there is a lack of high-quality data on suicide attempts much more muted or absent in other regions. in LMICs. 164 Mental, Neurological, and Substance Use Disorders Table 9.1 Estimated Incidence and Characteristics of Suicide in HICs and LMICs, based on WHO Global Health Estimates Change in age-adjusted Change in Age-adjusted suicide rate Rank of suicide as a cause suicide rate from 2000 to Number of number of in 2012 (per 100,000) of death in 2012 2012 (%) suicides Global Mean All deaths suicides in 2012 suicides Male + M:F age of due to Male + from 2000 to Male + Region (thousands) (%) female Male Female ratio suicide suicide (%) female Male Female 2012 (%) female Male Female a Global 804 100.0 11.4 15.0 8.0 1.87 44.1 1.44 15 13 22 −9.0 −26.3 −22.8 −32.2 a HICs 197 24.5 12.7 19.9 5.7 3.49 50.4 1.69 11 9 21 −2.9 −14.3 −17.5 −4.5 LMICsa 607 75.5 11.2 13.7 8.7 1.57 42.0 1.37 17 17 21 −10.8 −29.7 −24.2 −36.7 LMICs in six WHO regions Africa 61 7.6 10.0 14.4 5.8 2.47 37.6 0.66 24 27 37 38.0 1.5 2.0 0.7 Americas 35 4.3 6.1 9.8 2.7 3.61 40.4 1.02 22 15 33 17.5 −6.8 −7.0 −6.3 Eastern 30 3.7 6.4 7.5 5.2 1.45 39.7 0.77 27 27 26 32.0 −1.2 3.9 −7.2 Mediterranean Europe 35 4.3 12.0 20.0 4.9 4.08 45.3 1.35 11 8 22 −30.3 −37.9 −38.3 −37.2 South-East Asia 314 39.1 17.7 21.6 13.9 1.55 36.7 2.28 11 11 12 9.5 −10.8 −5.7 −17.4 Western Pacific 131 16.3 7.5 7.2 7.9 0.91 57.0 1.16 13 16 11 −46.6 −57.7 −55.9 −59.1 Note: HICs = high-income countries; LMICs = low- and middle-income countries; WHO = World Health Organization. a. Global figures, overall HIC figures, and overall LMIC figures include data for three territories that are not member states: Puerto Rico and Taiwan, China, are included with HICs; the West Bank and Gaza is included with LMICs. The figures for LMICs in the six WHO regions only include WHO member states. Suicide 165 Figure 9.1 Percent Change in Age-Adjusted Suicide Rate in Different There are two sources of data for suicide attempts: Regions of the World from 2000 to 2012 Based on WHO Global Health self-reports from community surveys and reports from Estimates emergency departments of general hospitals (where most suicide attempts that receive medical care are 5 0 treated). For the majority of the survey data and emer- –5 gency department data about suicide attempts available 2000–12 percent change –10 –15 from LMICs, the lack of standardized methods for iden- in suicide rate –20 tifying suicide attempts, methodological limitations, or –25 –30 unknown representativeness of the sample limit their –35 usefulness. –40 –45 One notable exception is the World Mental Health –50 Survey, which collected self-reported data on suicide –55 attempts from nationally representative samples in nine –60 HICs, four middle-income countries (MICs), and one es s ca as an e ia c al rie cifi op As tri fri ric ne ob nt ur low-income country (LIC) (Kessler and Ustun 2008). Pa un A me rra Gl t ou nE s n co a rn ite i A ec -E si Cs te me he th ed Based on the results of this survey, of persons 18 years om IC es I LM ou nt M co LM W inc nS si -in rn he le- of age or older from 2001 to 2007, the self-reported one- IC ste gh si nt M idd IC Hi Ea si L LM dm he IC year prevalence of suicide attempt is 0.03 per 100,000 for LM nt an si w- males and females in HICs, 0.03 for males and 0.06 for IC Lo LM Male and female Male Female females in MICs, and 0.04 for males and females in LICs. Combining this very crude result from a small number Note: LMICs = low- and middle-income countries; WHO = World Health Organization. of countries with the estimated global suicide rate in Figure 9.2 Suicide Rates by Gender and Age for Selected Regions, Based on WHO Global Health Estimates, 2012 a. Global (197 countries) b. 56 High-income countries (HICs) c. 141 Low- and middle-income countries (LMICs) 100 100 100 90 90 90 80 80 80 70 Suicide rate (per 100,000) 70 70 60 60 60 50 50 50 40 40 40 30 30 30 20 20 20 10 10 10 0 0 0 10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 Age (years) Age (years) Age (years) Male Female figure continues next page 166 Mental, Neurological, and Substance Use Disorders Figure 9.2 (continued) d. 46 LMICs in WHO Africa region e. 26 LMICs in WHO Americas region f. 16 LMICs in WHO Eastern Mediterranean region 100 100 100 90 90 90 80 80 80 Suicide rate (per 100,000) 70 70 70 60 60 60 50 50 50 40 40 40 30 30 30 20 20 20 10 10 10 0 0 0 10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 Age (years) Age (years) Age (years) g. 20 LMICs in WHO Europe region h. 11 LMICs in WHO South-East Asia region i. 21 LMICs in WHO Western Pacific region 100 100 100 90 90 90 80 80 80 Suicide rate (per 100,000) 70 70 70 60 60 60 50 50 50 40 40 40 30 30 30 20 20 20 10 10 10 0 0 0 10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 10 20 30 40 50 60 70 80 Age (years) Age (years) Age (years) Male Female Note: The countries included in each region are listed in annex 2 of WHO 2014a. HICs = high-income countries; LMICs = low- and middle-income countries; WHO = World Health Organization. Suicide 167 persons ages 18 years or older (15.4), globally there are geographic regions of large LMICs, like China (Phillips about 20 self-reported suicide attempts for each death and others 2002) and India (Patel and others 2012). by suicide in persons ages 18 or older; this amounts to Some of these differences can be attributed to limita- 15 million suicide attempts worldwide each year. tions or biases in the reporting of suicides, but most of The limited nationally representative data avail- the reported differences reflect real differences in suicide able from HICs suggest that the case-fatality of medi- rates. Given the magnitude of these differences, policy cally treated suicide attempts is greater for males than makers and planners should be cautious when transpos- females for all methods and increases with age, but it ing a prevention strategy from HICs to LMICs, from one is unknown whether this pattern is also true in LMICs nation to another, or even from one region to another (WHO 2014a). in a country. Development and ongoing quality control of registry systems that monitor the changing rates, demographic profile, and methods of fatal and nonfatal Methods of Suicide and Suicide Attempts suicidal behavior in the country or region is essential for Collecting information about the methods used in fatal planning and implementing interventions. and nonfatal suicidal behavior, the demographic pro- file of individuals who use different methods, and the case-fatality of the different methods is an impor- RISKS AND PROTECTIVE FACTORS IN LMICs tant component of a comprehensive suicide prevention plan. Unfortunately, only a minority of countries pro- The identification of risk and protective factors is a key vides method-specific data when reporting mortality component of any prevention strategy and guides the data to WHO, although International Classification of development of appropriate interventions. Risk fac- Diseases-10 (ICD-10) codes exist for all methods of sui- tors can be present in different categories—individual, cide. Of the 140 LMICs, only 36 provided data on suicide relationships, community, society, and health system— methods at any time after 2005, and these countries only that can have multiple points of overlap (WHO 2014a). accounted for 11 percent of all suicides in LMICs in 2012. There are several theoretical ways to conceptualize how In the absence of national-level data from WHO, it risk factors influence suicidal behaviors. One approach is necessary to consider reviews of subnational data. A to conceptualize risk factors is to view their influence as systematic review (Gunnell, Eddleston, and others 2007) being proximal versus distal. Proximal risk factors include of the global literature from 1990 to 2007 estimated psychiatric disorder, physical disorder, psychosocial life that about 30 percent of all suicides worldwide are crisis, availability of means, and exposure to models of caused by pesticide self-poisoning, most of which occur suicide. Distal risk factors include genetic susceptibility/ in LMICs, particularly in rural areas where residents loading, personality characteristics such as impulsivity or practice small-scale agriculture and have easy access to aggression, early traumatic events, and neurobiological pesticides. Based on this result, pesticide ingestion is the disturbances such as serotonin dysfunction (Hawton and most common method of suicide globally. However, it van Heeringen 2009). is probable that the choice of method varies greatly by There are also different patterns of risk across the life- region, gender, age, urban versus rural residence, and span. For example, risk factors for the elderly differ from over time, so each nation must develop standardized those for adolescents and young adults. What is universal methods for routinely obtaining this information to help is that the greater the number of risk factors present, the inform country-specific and community-specific means greater is the likelihood of a range of suicidal behaviors restriction strategies. For countries that already provide (Phillips and others 2002). ICD-10 cause of death mortality data to WHO, this could be accomplished relatively easily by mandating that all reports of accidental deaths include the corre- Risk Factors sponding X-code. The relative importance of certain risk factors differs by country and region, such as age of onset of a psychiatric disorder, religious orientation and practice, geographical Role of Surveillance in Suicide Prevention in LMICs location, age ranges, and gender distribution. Even within The available evidence suggests that substantial a region, national and intranational differences exist in cross-national variation in the rates, demographic pro- the prevalence of risk factors; any listing of risk factors file, and methods of suicide and attempted suicide is the may not apply to all LMICs, even in the same region. rule rather than the exception. Other reports also indi- Risk factors are variable over time and may be cate large differences in suicide rates between different influenced by the rapidity of change occurring within 168 Mental, Neurological, and Substance Use Disorders a country or region, such as by the increasing global Proximal Risk Factors influence of the Internet, migration from rural to Mental Disorders and Alcohol Misuse urban areas, and movement of ethnic populations The classic method of investigating characteristics of (Malakouti and others 2015). For example, in Chile, individuals who have died by suicide is through a from 1998 to 2011, the age range with the highest sui- psychological autopsy, involving interviews with key cide rates changed, from 40–59 years between 1998 and informants and examination of official records (Hawton 2006 to 25–39 years between 2006 and 2009 (Otzen and others 1998). This approach has shown that in and others 2014). Qualitative studies are needed to many HICs, psychiatric disorders are present in about identify culturally relevant risk factors and to under- 80–90 percent of people who kill themselves and con- stand how risk factors may be connected to suicidal tribute 47–74 percent to population risk of suicide behaviors in different sociocultural contexts (Mars and (Cavanagh and others 2003; Cheng and others 2000). others 2014). Affective disorder is the most common psychiatric A review of risk factors reported that the profiles disorder, followed by substance (especially alcohol) in LMICs differed from HICs in some respects, while misuse and schizophrenia. A study based on the Global certain risks were universal (Phillips and others 2002; Burden of Disease 2010 stated that the relative risk of Vijayakumar and others 2005). In Africa, reported suicide in an individual with major depressive disorder risk factors were similar for suicide and suicide was 19.9 (odds ratio (OR) = 9.5–41.7); with schizophre- attempts, and included interpersonal difficulties, nia, 12.6 (OR = 11.0–14.5); and with alcohol dependence, mental and physical health problems, socioeconomic 9.8 (OR = 9.0–10.7) (Ferrari and others 2014). problems, and drug and alcohol use and abuse (Mars Psychological autopsy studies reveal that 40 percent and others 2014). of suicides in China, 35 percent in India, and 37 percent In a recent review of 17 published studies from Latin in Sri Lanka had a diagnosis of depression (Abeyasinghe America and the Caribbean, the main risk factors for and Gunnell 2008; Phillips and others 2002; Vijayakumar suicide attempts included major depressive disorder, and Rajkumar 1999). However, a study in Pakistan family dysfunction, and prior suicide attempt; the main found that 73 percent had depressive disorder (Khan risk factors for death by suicide were male gender and and others 2008). In LMICs, the role of mental disorders major depressive disorder. Although the methodologi- is accorded less importance; equal or more importance is cal quality of most of the studies was low, the authors given to other sociocultural and environmental factors. concluded that the majority of relevant risk factors for Although their absolute level of risk is somewhat lower suicide and suicide attempts in the region were similar in LMICs, people with depression, mental disorders, to those observed in Western societies, but they were or alcohol abuse or dependence are at a higher risk of different from those reported in Eastern societies (Teti suicide (WHO 2012). and others 2014). Alcohol misuse, particularly dependence, is strongly Risk factors that appear to be universal include associated with suicide risk in HICs and LMICs. youth or old age, a mental disorder, low socioeco- The severity of the disorder, aggression, impulsivity, and nomic standing, substance use, and previous suicide hopelessness seem to predispose to suicide. Life events, attempts. Mental disorders occupy a premier position stressors, and depression are not necessarily mutually in the matrix of causation, although their relative exclusive, although they may be located at different points contribution to suicide differs across countries. Loss, along the pathway to suicide. interpersonal conflict, suicide bereavement, chronic pain, chronic illness, and intimate partner violence increase the risk of suicide when they are associated Physical Disorders with one another or when they are associated with Suicide is associated with several physical disorders. another high-risk condition. In a study from Nigeria (Chikezie and others 2012), Recent stressful life events play a role in HICs and 34.7 percent of HIV/AIDS patients versus 4.0 percent LMICs, although their nature may differ. For exam- of controls expressed suicidal ideation in the preceding ple, agents such as social change are more important month, with 9.3 percent attempting suicide in the six in LMICs (Vijayakumar and others 2005). Access to months prior to the study. means heightens risk in HICs and LMICs, but the specific means used may vary. Regional and national Psychosocial Life Crises suicide rates vary in relation to geographic preferences Poverty, low education, social exclusion, gender dis- for, and access to, high-lethality methods (Yip and advantage, conflict, and disasters are the major social others 2012). determinants of mental health in LMICs (Patel 2007); Suicide 169 these factors are also associated with suicide. In Turkey, Exposure to Models from 1990 to 2010, economic problems, relationship Risk of suicidal behavior can be influenced by exposure problems, and educational failure were the most com- to similar behavior by other people. mon reasons for suicide (Oner, Yenilmez, and Ozdamar A substantial body of evidence indicates that certain 2015). In Brazil, from 1980 to 2006, the most dominant types of media reporting and portrayal of suicidal sociodemographic characteristics of those who died behavior can influence suicide and self-harm in the by suicide were low educational level and single status general population (Pirkis and Blood 2010). Newspaper (Lovisi and others 2009). Another study from Brazil reporting of suicides can be particularly influential if it found that income inequality represents a community- is sensational, if it includes dramatic headlines and pic- level risk factor for suicide rates (Machado, Rasella, and tures, if it reports methods of suicide in detail, and if the Dos Santos 2015). subject is a celebrity (Stack 2003). One of the most distressing features of suicide in Urban versus Rural Locations LMICs is the frequent occurrence of suicide pacts and Globally, suicide rates are higher in urban than in rural family suicides, which constitute an estimated 1 percent areas, but these can vary across countries by age and of suicides. Family suicides are often a suicide-homicide, gender. In LMICs, living in a rural area increases risk. In in which the adults murder their children prior to their China, the suicide rates are three times higher in rural own suicide. These suicides are frequently driven by areas than urban areas (Cao and others 2000; Phillips and debt, poverty, and other social issues rather than by others 2002); in Sri Lanka, the rural suicide rate is twice depression or mental disorders (Gupta and Gambhir that of urban areas (Jayasinghe and de Silva 2003); and in Singh 2008; Vijayakumar and Thilothammal 1993). India, about 90 percent of the suicides occur in rural areas (Gajalakshmi and Peto 2007; Joseph and others 2003). Distal Risk Factors Availability of Means and Methods Several biological systems might be involved in suicidal When a person is contemplating suicide, access to spe- behavior, particularly with regard to the serotonin, cific methods might be the factor that leads from suicidal noradrenalin, and hypo-thalamic-pituitary-adrenal axis thoughts and plans to action. systems (Mann 2003). The easy availability of highly lethal methods is a Family history of suicide increases the risk at least significant factor in suicides in LMICs. As many as twofold, particularly in girls and women, independent of 30 percent of global suicide deaths might involve inges- family psychiatric history (Qin, Agerbo, and Mortensen tion of pesticides (Gunnell, Eddleston, and others 2007). 2003). Studies from India (OR = 1.33; confidence inter- This situation is compounded by the limited availability val (CI) = 0.59–3.09) (Vijayakumar and Rajkumar 1999) of appropriate health care services and professionals, and China (OR = 3.9; CI = 2.4–6.3) (Phillips and others and by the complexity of managing pesticide overdoses 2002) corroborate these findings. that lead to increased fatalities. In Turkey, from 1990 to 2010, the most common History of Suicide Attempts suicide method was hanging, and men used firearms A history of self-harm or suicide attempts is seen as more frequently than women did (Oner, Yenilmez, and a very strong risk factor. Studies from China, India, Ozdamar 2015). In Brazil, the most common methods and Sri Lanka reveal that around one-third of those were hanging, firearms, and poisoning (Lovisi and who died by suicide had made a prior suicide attempt others 2009). In Africa, the most frequently used meth- (Abeysinghe and Gunnell 2008; Phillips and others 2002; ods of suicide were hanging and pesticide poisoning Vijayakumar and Rajkumar 1999). (Mars and others 2014). In a systematic review and meta-analysis of the Early Traumatic Events most common methods of suicide in the Eastern Childhood adversities, including physical, emotional, Mediterranean region, the pooled proportions of and sexual abuse, have been associated with higher risk hanging, self-immolation, and poisoning were 39.7, for suicide. A highly significant relationship between 17.4, and 20.3 percent, respectively (Morovatdar and domestic violence and suicidal ideations has been found others 2013). More females died by self-immolation in many LMICs, with 48 percent of women in Brazil, than males (29.4 percent versus 11.3 percent); more 61 percent in the Arab Republic of Egypt, 64 percent males died by hanging than females (38.8 percent versus in India, 11 percent in Indonesia, and 28 percent in the 26.3 percent); and more females died by poisoning than Philippines reporting suicidal ideations and domestic males (32.0 percent versus 19.0 percent). violence (WHO 2001). 170 Mental, Neurological, and Substance Use Disorders In a study of the relationship between childhood Youth trauma and current suicide risk in 1,380 individuals ages Many LMICs experience peaks in suicide rates among 14–35 years, in the city of Pelotas, Brazil (Barbosa and young adults. These peaks likely reflect a combination others 2014), suicide risk was associated with all types of factors, including the use of high-lethality methods of childhood trauma. Suicide risk was increased in emo- in impulse (low intent) suicide attempts; relationship tional neglect (OR = 3.7), physical neglect (OR = 2.8), stresses and arranged marriages, particularly in young sexual abuse (OR = 3.4), physical abuse (OR = 3.1), and women; and the high incidence of impulsive suicide emotional abuse (OR = 6.6). attempts in response to socioeconomic stressors, such as job loss, substantial disparities in incomes, and inabil- ity to meet role obligations in a changed environment Vulnerable Groups in LMICs following large-scale privatization and liberalization of Women the economy (Schlebusch 2005). The breakdown of the Several social and cultural factors make women vulnera- joint family system that had provided emotional support ble, especially in LMICs in South Asia. These include the and stability was also an important contributing factor practice of arranged and often forced marriages that trap (Thara and Padmavati 2010). women in unwanted marriages; some opt for suicide as a means of escape. Young persons who love each other, but Farmers whose families disapprove of their relationship, may take In Brazil, suicide risk was higher among agricultural their lives, either together or alone. workers than nonagricultural workers, elevated in In Turkey, from 1990 to 2010, the number of regions that used more pesticides, and greatest in suicides in females ages 15–24 years was significantly regions that produced more tobacco. These findings higher than in males. The leading reason for suicide in suggest that the combined effects of pesticide and females was relationship problems (Oner, Yenilmez, and tobacco exposure may be linked to higher suicide Ozdamar 2015). risk among agricultural workers (Krawczyk and others Self-immolation, seen almost exclusively in LMICs 2014). Farmer death from pesticide self-poisoning is (10–30 percent versus 0.06–1.00 percent in HICs), has very common in several LMICs, including China, Fiji, emerged as a major cause of death and disability in parts India, Indonesia, Sri Lanka, and Suriname (Phillips and of the Middle East and Central Asia, especially among others 2002; Vijayakumar and others 2005). A common young married Muslim women (Campbell and Guiao reason includes falling into debt traps following crop 2004). Self-immolation remains the only lethal means failure. When this difficulty is coupled with the easy used more by women than men. In the Islamic Republic availability of a lethal means of suicide, the situation of Iran and in Pakistan, 81 percent of self-immolation is becomes particularly dangerous. by women; in Sri Lanka, the rate is 79 percent; in India, it is 64 percent. Marital conflicts and failed love affairs Refugees and Internally Displaced Persons were identified as the most common reasons (Ahmadi Refugee status, or seeking asylum, puts individuals and others 2009). at significant risk for suicide (Kalt and others 2013). Pressure on women to bear children soon after mar- More than 59 million people were displaced in 2014; riage, failure to become pregnant, and infertility carry 86 percent of these were in LMICs. The least-developed severe social stigma, leading some women to resort to nations provided asylum to 3.6 million people (UNHCR suicide. Domestic violence is fairly common; its practice 2014). Most refugees in LMICs are residents of refugee is, to a large extent, socially and culturally condoned in camps with poor infrastructure and limited services many LMICs. In a population-based study on domestic (McColl, McKenzie, and Bhui 2008). violence, 9,938 women were studied in different parts Suicidal behavior in refugees is often not reported, of India and across sections of the society. An estimated because it is considered politically sensitive. A review 40 percent experienced domestic violence (Kumar and suggests that the overall prevalence of suicidal behavior others 2005); 64 percent showed a significant correlation among refugees ranges from 3.4 percent to 34.0 percent between domestic violence and suicidal ideation (WHO (Vijayakumar and Jotheeswaran 2010). The results of a 2001). Domestic violence was found in 36 percent of study of adults in refugee camps showed that 50 percent suicides and was a major risk factor (OR = 6.82; of the sample had serious psychological problems, with CI = 4.02–11.94) (Gururaj and others 2004). However, interventions often not available; suicidal thoughts were relatively little is known about domestic violence as a common among mothers (Rahman and Hafeez 2003). risk factor across LMICs, and it is an important area for Children and adolescents formed an especially vulner- future research. able group, since they constitute almost 50 percent of Suicide 171 the world’s internally displaced and refugee populations. Religious and Spiritual Beliefs Accordingly, it is essential to take steps to provide appro- Religious and strong cultural beliefs that discourage sui- priate interventions (Reed and others 2012). cide are seen as major protective factors. The protective value of religion and spirituality probably arises in part Sexual Minorities from providing access to a socially cohesive and support- In many LMICs, discrimination against sexual minori- ive community. Islam and Christianity, and specifically ties, such as lesbians, gays, bisexuals, and transgenders, Catholicism, prohibit the taking of one’s own life, and is ongoing, endemic, and systemic. This problem can this prohibition can have a strong inhibitory effect on lead to the continued experience of stressful life events, suicidal behavior. Data from Islamic countries and from such as loss of freedom, rejection, stigmatization, and countries in Latin America and the Caribbean that are violence that can lead to suicidal behaviors (Haas and predominantly Catholic bear this out; however, the others 2011). There have been no studies that have com- strong stigma associated with suicide in these cultures pared suicide rates among sexual minorities in countries may mean that underreporting is likely. The rates of sui- with or without social acceptance of alternative lifestyles. cide in Islamic countries are very low; for example, Saudi Arabia and Syria have a similar rate of 0.4 per 100,000 Survivors of Suicide Loss (WHO 2014a). Islam also prohibits alcohol consump- People bereaved by the suicide of loved ones or a close tion, a known risk factor for suicide. contact often experience significant emotional distress as A survey of young people from nine Latin American a result of their loss. These feelings are often accompanied and Caribbean countries reported that attendance at by feelings of stigma, loss of trust, and social isolation. religious services and connectedness with parents and Many survivors experience suicidal thoughts themselves. school reduced risk behaviors (Blum and others 2003). Every year, an estimated four million people may be A study from India revealed that religiosity acted as a actively experiencing the aftermath of a suicide, many strong protective factor against suicide (Vijayakumar of them children, due to the high proportion of young 2002). Due to the lack of reliable data, the debate married women in China and India who die by suicide. remains open as to whether it is the religious beliefs per Many LMICs do not provide programs for survivors se or the social connectedness that occurs in the context in any systematic way. Families in which suicide has of religious involvement that is protective. occurred may be ostracized and isolated, and the mar- riage prospects of sisters and daughters of people who Positive Coping Strategies and Well-Being die by suicide may be marred (Khan and Prince 2003). Subjective personal well-being and effective positive These attitudes may affect the ways in which people coping strategies seem to be protective against suicide respond to survivors and may reduce the likelihood that (Sisask and others 2008). However, ample debate remains survivors seek what limited services might be available. regarding the international measures of national and individual well-being, making the relationship between well-being and suicide less than simple. Protective Factors Use of upstream approaches, such as addressing risk The role of protective factors, such as resiliency, social and protective factors early in the life course, has the support, self-esteem, problem-solving skills, and religious potential to shift the odds in favor of more adaptive affiliation have not been as well studied as risk factors. outcomes. Moreover, upstream approaches may simul- taneously impact a wide range of health and societal Strong Personal Relationships outcomes, such as suicide, substance abuse, violence, and The promotion and maintenance of healthy close rela- crime (Jané-Llopis and others 2005). tionships can increase resilience and act as a protective Figure 9.3 provides a list of key risk factors for suicide factor against the risk of suicide. In a study in Brazil, aligned with their possible interventions. the protective factors for boys and girls included having good family relationships and feeling liked by friends and teachers, and these factors seemed beneficial (Anteghini SUICIDE PREVENTION IN LMICs and others 2001). Similarly, a survey of adolescents from nine Caribbean countries reported that strong connec- This section summarizes the evidence for suicide pre- tions with family and school provided the best protective vention in LMICs. It provides an overview of poten- factors (Blum and others 2003). Relationships are espe- tial populationwide, community-based, and health and cially protective for adolescents and elderly persons, who social care interventions and describes the development have higher levels of dependency. of national suicide prevention strategies. 172 Mental, Neurological, and Substance Use Disorders Figure 9.3 Risk Factors and Possible Interventions Key risk factors for suicide aligned with relevant interventions (Lines reflect the relative importance of interventions at different levels for different areas of risk factors) Barriers to accessing Health systems health care Access to means Society Behavior inappropriate media Mental health policies reporting Stigma associated with Policies to reduce help-seeking behavior harmful use of alcohol Disaster, war, and conflict Access to health care Stresses of acculturation Universal and dislocation Restriction of access Community to means Discrimination Responsible media reporting Trauma or abuse Raising awareness about mental health, substance Sense of isolation and use disorders, and suicide lack of social support Relationship Relationship conflict, Interventions for discord, or loss vulnerable groups Previous suicide attempt Gatekeeper training Selective Mental disorders Crisis helplines Follow-up and Harmful use of alcohol commumity support Assessment and Job or financial loss management of Individual suicidal behaviors Indicated Hopelessness Behaviors assessment and management of mental Chronic pain and substance use disorders Family history of suicide Genetic and biological factors Source: WHO 2014a. Suicide was once commonly viewed as a mental mental disorders. Moreover, in LMICs, the availability health problem that needed to be addressed primarily of mental health professionals needed to deliver mental by clinical intervention, especially by the treatment of health interventions is often limited. depression. Suicide is now recognized as a public health WHO has produced several documents on suicide pre- issue that should be addressed by social and public vention. Based on these documents and recent literature, health programs, as well as clinical activities targeting table 9.2 highlights potential interventions in LMICs; Suicide 173 Table 9.2 Potential Interventions for Suicide in LMICs Population platform interventions Universal prevention and health promotion Restrict the availability of toxic pesticides and other commonly used methods Decriminalize suicide Reduce the availability and excessive use of alcohol and illicit drugs Work with national and local media organizations to limit inappropriate reporting of suicides Conduct campaigns to reduce the stigma associated with suicide and mental disorders and to encourage help-seeking behavior Provide adequate economic and welfare support to individuals who are unemployed, disabled, or destitute Community platform interventions Selective prevention and health promotion NGOs: provide suicide hotlines and crisis centers, and promote social cohesion and interpersonal support in communities and families Initiate school-based mental health promotion programs to enhance psychological resilience, problem-solving skills, and appropriate help-seeking behavior Organize community-based safe storage activities for pesticides, other poisons, and medications Provide gatekeeper training to teachers, people looking after refugees, police, social workers, practitioners of alternative systems of medicine, traditional healers, and other individuals who interact with suicidal individuals Implement communitywide health promotion programs to encourage help-seeking for psychological problems and reduce alcohol and drug abuse, child abuse, and domestic violence Health care platform interventions Indicated (targeted) prevention and care for persons with mental, neurological, and substance disorders and their families Conduct brief interventions for people who have attempted suicide Train primary health care workers in the identification and management of individuals at high risk of suicidal behavior Improve health care professionals’ identification and treatment of depression and alcohol or drug abuse Provide regular follow-up, social support, and (if appropriate) cognitive behavioral therapy or other psychological treatment to individuals who have attempted suicide Improve the medical management of poisoning with pesticides and other poisons associated with high case-fatality Establish services to support individuals bereaved by suicide (postvention services) Note: Given the wide variability of suicidal behavior between and within countries, any interventions must be based on local conditions (for example, commonly used high-lethality methods); interventions from other countries or jurisdictions can be considered but should not be implemented prior to conducting a formal assessment of their local feasibility and appropriateness. However, many LMICs do not have quality vital registration systems to identify suicidal deaths, or community-based or hospital-based monitoring programs to identify suicide attempts. This deficit poses a serious dilemma for stakeholders in LMICs. It is not feasible to delay the initiation of suicide prevention activities until a comprehen- sive monitoring system of suicidal behavior is operational; it is appropriate to integrate monitoring in the target communities in parallel with the initiation of the intervention programs. LMICs = low- and middle-income countries; NGOs = nongovernmental organizations. the relevance of these to a particular LMIC depends on of suicide. In this section, we consider interventions its epidemiology of suicide, key risk factors, and social specific to suicidal behavior, such as restricting access context, as well as the available resources in the country. to commonly used methods of suicide, and those to The evidence is of mixed quality; in some cases, improve the mental health of the population in general, it extrapolates from research in HICs. Furthermore, where an impact on suicide seems probable. because of the low incidence of suicide, the evidence for several of the interventions comes from trials that have used suicide attempts, rather than suicide, as the primary Population Platform Interventions outcome measure. Restricting Access to Lethal Means Some of the interventions highlighted in other chap- Research has demonstrated that one of the most effec- ters, such as those to reduce the incidence of alcohol mis- tive approaches to reducing suicide is restricting access use and depression, will help to decrease the incidence to highly lethal and commonly used methods (Mann 174 Mental, Neurological, and Substance Use Disorders and others 2005). Suicidal impulses are often short have an adverse impact on suicide rates (Chen and others lived; if access to high-lethality methods is restricted, the 2014). Many LMICs do not have effective media regula- impulse may pass or a less lethal method may be chosen. tory bodies or media guidelines such as those developed Most people who survive a suicide attempt do not go on by WHO (http://www.who.int/mental_health/prevention to kill themselves. /suicide/resource_media.pdf). If poor reporting is an Pesticide self-poisoning accounts for a high pro- issue, it is important to work with national media orga- portion of all suicides in LMICs. In Sri Lanka, where nizations and journalists to develop local guidelines and pesticide poisoning accounted for two-thirds of all provide regular feedback on their reporting. suicides in the 1980s, a series of bans on the import of the most toxic pesticides was followed by a halving Other Populationwide Interventions in suicide rates (Gunnell, Fernando, and others 2007). Stigma. Many people who die by suicide have not In recent years, China and the Republic of Korea have sought help for their emotional distress. The stigma asso- followed Sri Lanka’s lead by banning some of the most ciated with mental disorder, the belief that nothing can toxic pesticides. Other methods of suicide potentially be done, and, in some countries, the criminalization of amenable to means-restriction interventions include suicide contribute to this reluctance to seek help. Media, gun control legislation and protective barriers at school-based, and other campaigns to address this issue suicide hotspots. may promote appropriate help-seeking, although robust research evidence to support this approach is lacking Decriminalization (Dumesnil and Verger 2009). In a recent study, 25 of the 192 countries investigated had specific laws and punishments for attempted suicide Examination Stress. In many LMICs with fierce compe- (Mishara and Weisstub 2014). These countries are prin- tition for places in higher education, examination failure cipally LMICs. The impacts of criminalizing suicide are is a recognized risk factor for suicide. In India, 1.8 percent the following: of suicides were by students following failure in examina- tions (NCRB 2014). Similar patterns have been reported • People may not present for care following a suicide in Malaysia, Pakistan, and Sri Lanka. An example of attempt and so not receive the medical or psycholog- good practice in this area is work by Sneha, a nongov- ical help they may require. ernmental suicide prevention organization in India. • It stigmatizes suicide and may discourage help-seeking. Sneha worked with the media to raise awareness of the • Police interrogation of people who have attempted issue and undertook education and awareness training suicide causes increased distress, shame, and guilt, for parent associations. In Tamil Nadu, India, a new law and may lead to further suicide attempts. came into effect in 2003 that allowed students who failed • There may be gross underreporting of attempted sui- examinations to be able to retake them within one month cides, leading to underestimation of the magnitude and pursue higher studies without losing an academic of the problem. year (Vijayakumar and Armson 2005). In 2004, there Changing the laws should result in improved help- were 407 suicides due to examination failure (suicide rate seeking behavior, reduce stigmatization, provide better 61.6 per 100,000 students), whereas in 2013 there were data, and save lives. 277 suicides (suicide rate 24.7) among students in Tamil Nadu. Other states in India, including Andhra Pradesh Alcohol and Drug Misuse and Maharashtra, have enacted similar laws. The contribution of alcohol and drug misuse to the bur- den of suicide varies from country to country depending Economic Issues. Poverty, debt, chronic ill-health, and on cultural norms. Evidence from HICs suggests that low socioeconomic position are risk factors for suicide restricting alcohol availability by pricing or restric- in LMICs (Knipe and others 2015). Adequate welfare tions on purchasing may lead to reductions in suicide provision for these more vulnerable members of society (Pridemore, Chamlin, and Andreev 2013), but this has is important to reduce risk but poses a challenge to the not been evaluated in LMICs. struggling economies of many LMICs. Media Reporting Improving the portrayal of suicide in the media is an Community Platform Interventions important component of suicide prevention. Sensational Services of Nongovernmental Organizations reporting can raise awareness (cognitive availability) of Most LMICs do not have the financial or person- high-lethality suicide methods that, if popularized, may nel resources to support suicide prevention programs, Suicide 175 especially health care system–driven models. It has schoolteachers, people caring for refugees and victims become imperative to develop low-cost interventions of disaster, hospital emergency department staff, prac- that can be delivered by lay volunteers or community titioners of traditional and alternative medicine, police, health workers. prison staff, and youth leaders. Training gives these This enormous gap in mental health services has individuals the skills to identify and respond to at-risk been the catalyst for the emergence of nongovernmental individuals (WHO 2012, 2014a). mental health organizations. Many African and South- Although research evidence to support this activity East Asian countries have such organizations, often is limited to institutional settings (Mann and others taking the form of suicide prevention centers, staffed 2005), it appears to be intuitively sensible and is valued largely by volunteers and operating as crisis centers or by front-line personnel and communities. hotlines, providing free service in many LMICs. For example, the Beijing Suicide Research and Prevention Other Community Platform Interventions Center in China established a national hotline and Recently, there has been interest in multifaceted, provides standardized training to other hotline services community-based approaches to improving the iden- around the country. tification and treatment of depression and reducing The primary goal of these prevention centers is to suicide. Hungary participated in the European Alliance provide emotional support to suicidal persons through against Depression Programme. The program includes befriending and counseling in person or by telephone. four levels of intervention: general practitioner training In many countries, as the primary or sole agency for sui- workshops, a public information campaign, training cide prevention, they have enlarged their perspectives by community facilitators (gatekeepers), and interventions being proactive in rural and remote areas and in special targeted at high-risk groups. Szekely and others (2013) populations. Although many innovative programs for report data from the intervention (population 77,000) raising awareness and increasing help-seeking behavior and control (population 163,000) regions of Hungary; have been developed, most have not been evaluated they find evidence of a significantly greater reduction (Vijayakumar and Armson 2005). in suicide in the intervention region compared with the control area. School-Based Interventions A multifaceted suicide prevention program in a There is mixed evidence concerning the effectiveness Brazilian municipality, the Program for Promotion of of school-based interventions for preventing suicide. In Life and Suicide Prevention, was designed to reduce sui- the largest randomized control trial (RCT) carried out cide rates in the general population (Conte and others to date—the Saving and Empowering Young Lives in 2012). The components of the program included trying Europe trial—mental health awareness and skills training to break taboos and talking about death, improving and reduced the incidence of suicidal thoughts and attempts streamlining the process of care, and reorganizing work among secondary school children (Wassermann and processes in the basic network. Although suicide rates others 2015). More research is needed in this area in fell in the municipality, the lack of comparison informa- LMICs. tion from control areas means it is not possible to deter- mine whether the reduction was due to the program or Safe Storage of Pesticides other influences. Multiple projects have investigated approaches to Campaigns to reduce stigma associated with suicide restricting access to pesticides in farming communities and encourage help-seeking have been suggested as in rural Asia. These include studies of lockable safe a population-level intervention; such campaigns may storage boxes in Sri Lanka (Hawton and van Heeringen also be appropriately carried out by local communities. 2009; Konradsen and others 2007) and a centralized Activity might also focus on groups identified as being at community pesticide storage facility in southern India high risk in the particular community, such as victims of (Vijayakumar and others 2013). These approaches show domestic abuse, people who abuse alcohol, or those who some promise, although the possibility of adverse effects engage in gambling. has been raised. A randomized trial of locked storage An unusual intervention in the Islamic Republic of Iran devices that is enrolling 200,000 people is underway in used videos documenting the stories of self-immolation Sri Lanka (Pearson and others 2011). victims (Ahmadi and Ytterstad 2007). Young women from socioeconomically deprived groups who were iden- Gatekeeper Training tified as at high risk were targeted. There was some evi- A gatekeeper is anyone in a position to identify whether dence of a beneficial effect on self-immolation and overall someone may be at risk of suicide. Gatekeepers include suicide attempts compared with a nonintervention city. 176 Mental, Neurological, and Substance Use Disorders Such interventions need to be designed carefully to training and initial and longer-term care, and include avoid possible unanticipated effects, such as glamorizing notes of caution about overuse of gastric lavage, the suicide. appropriate use of antidotes—for example, atropine for organophosphate poisoning—and careful attention to respiratory failure. Health Care Platform Interventions Brief Intervention and Contact Disasters and Refugees Few interventions for people presenting to clinical LMICs are particularly prone to natural disasters, war, services have been evaluated in LMICs. An exception and food shortages. These problems often result in is the WHO’s multisite RCT of the provision of brief large numbers of displaced people or refugees. These intervention and contact (BIC) to people who presented people are at heightened risk not only because of their to hospital emergency departments in Brazil, China, displacement, but also because of the traumas, physical India, the Islamic Republic of Iran, and Sri Lanka. BIC and psychological, they may have experienced. Those comprised a one-hour individual information session, in contact with such individuals should be appropri- as close to the time of discharge as possible, combined ately trained to be aware of their vulnerabilities and with periodic follow-up after discharge. The 18-month how to respond. follow-up reported significantly fewer deaths from suicide in the intervention arm than the control arm Monitoring and Reporting Systems (treatment as usual) (Fleischmann and others 2008), Reliable and timely information on the prevalence, although surprisingly there was no impact on the inci- demographic patterns, and methods employed in sui- dence of repeat (nonfatal) suicide attempts (Bertolote cides and suicide attempts is essential for the devel- and others 2010). opment and monitoring of suicide prevention efforts Another brief intervention that has attracted atten- (WHO 2012). It is essential to involve community and tion in recent years is mailing a series of supportive nongovernmental organizations at multiple levels to postcards to people in the 12 months after a suicide address this issue in terms of monitoring, reporting, and attempt. A recent systematic review found no strong evi- providing interventions. dence of an effect of this sort of intervention in studies A direct transference of the methodologies used in largely carried out in HICs (Milner and others 2015). HICs is unlikely to be efficacious in LMICs. The sig- However, the one RCT conducted in an LMIC, the nificant differences in gender ratio, age structure, and Islamic Republic of Iran (Hassanian-Moghaddam and methods for suicide between HICs and LMICs mean others 2011), was more promising. The study showed that interventions have to be suitably adapted to address a reduction in suicidal ideation, suicide attempts, and local requirements and be consistent with local social number of attempts at one-year follow-up. This trial and cultural practices. should be replicated in other LMICs. In China, intervention by messaging through mobile National Suicide Prevention Strategies phones was piloted in 15 people who had attempted A key step in acting to prevent suicide is to identify and suicide; most participants considered the text message engage the key national stakeholders in developing a contacts an acceptable and useful form of help (Chen, national suicide prevention strategy. The Ministry of Mishara, and Liu 2010). However, a subsequent three- Health is the most appropriate body to lead strategy arm RCT comparing telephone contact, cognitive ther- development. apy, and controls showed no evidence of a beneficial Under the WHO Mental Health Action Plan 2013– effect on repeated suicide attempts, depression scores, 2020, member states have committed to work toward or quality of life at one-year follow-up, although loss to the global target of reducing the suicide rate in countries follow-up was high in all three treatment groups (Wei by 10 percent by 2020. WHO has produced recommen- and others 2013). dations for suicide prevention interventions in several documents, including the Mental Health Global Action Improving the Medical Management of Poisoning Program (WHO 2010a), Public Health Action for the with Pesticides Prevention of Suicide (WHO 2012), and Preventing The appropriate medical management of pesticide Suicide: A Global Imperative (WHO 2014a), which self-poisoning may reduce case-fatality. The WHO has provides evidence-based technical guidance to expand produced guidelines on the clinical management of pes- service provision in countries. Sadly, few LMICs have ticide intoxication (WHO 2008); these guidelines should developed national prevention strategies. Malaysia and be reviewed by local health services. The guidelines cover Sri Lanka are exceptions, although Sri Lanka’s strategy Suicide 177 is no longer operational. In India, suicide prevention A substantial minority of individuals who attempt is included in the country’s national mental health suicide or die by suicide in these settings does not have a program. mental disorder. Psychosocial and economic risk factors Although many risk factors for suicide are shared by need to be acknowledged, and interventions need to be all countries, their relative importance in determining developed that target these factors. In LMICs, suicide the local incidence of suicide varies. The first step in prevention is more of a social and public health objective informing priority areas for suicide prevention is to than a traditional mental health sector objective. collect good quality, nationally representative data on Before intervening, information about the prevalence, the age- and gender-specific incidence of suicide, the demographic patterns, and methods of suicide in the methods used by those who take their lives, and the key country or community is needed. Data from represen- risk factors. Guidelines by WHO to set up a surveillance tative locations on the pattern of deaths is particularly system and the process to be followed can be accessed important in countries without effective registry systems. from the STEPwise approach to surveillance at http:// Several evidence gaps exist. A more refined estimate of the www.who.int/chp/steps/en. burden and modeling that focuses on risk factor abate- ment, resilience enhancement, and intervention effects will effectively direct future suicide prevention activities. COST-EFFECTIVENESS OF PREVENTION EFFORTS NOTE The cost of treating suicide attempts, particularly self- poisoning by pesticides in LMICs, is high (Sgobin and Portions of this chapter are based on work that will appear in the International Handbook of Suicide Prevention, 2nd edition, others 2015; Wickramasinghe and others 2009). Suicide forthcoming from Wiley. prevention control measures may need to be tailored to The authors are very grateful to Mr. Sujit John, Senior the context of a specific country, taking into consideration Research Coordinator, Schizophrenia Research Foundation, the epidemiological, geographic, and gender distribution for his technical assistance in the preparation of the chapter. of suicide, political will, perceptions of stigma, legisla- World Bank Income Classifications as of July 2014 are as tion, and resource availability to deliver appropriately follows, based on estimates of gross national income (GNI) designed prevention programs. As such programs are per capita for 2013: developed, there will be a need to generate cost and cost- effectiveness information. Although there have been some • Low-income countries (LICs) = US$1,045 or less promising interventions in LMICs, the evidence of cost- • Middle-income countries (MICs) are subdivided: effectiveness remains sparse, and evidence on costs and a) lower-middle-income = US$1,046 to US$4,125 cost-effectiveness from HICs may not be relevant (WHO b) upper-middle-income (UMICs) = US$4,126 to US$12,745 2010b). No economic evaluation was conducted for the • High-income countries (HICs) = US$12,746 or more. multicountry RCT of BIC (Fleishmann and others 2008), but the clinical costs were equal to treatment as usual. Chapter 12 in this volume (Levin and others 2015) pro- REFERENCES vides a review of costs and cost-effectiveness for mental health interventions more broadly. Abeyasinghe, R., and D. Gunnell. 2008. “Psychological Autopsy Study of Suicide in Three Rural and Semi-Rural Districts of Sri Lanka.” Social Psychiatry and Psychiatric Epidemiology 43 (4): 280–85. CONCLUSIONS Ahmadi, A., R. 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Certain interventions that promote mental tion interventions foster the positive mental health health, prevent MNS disorders, and protect people and well-being of the general population. Fairly good are most appropriately delivered on a populationwide evidence is available from high-income countries (HICs) basis. Legislation, regulations, and public information for interventions across these platforms and along the campaigns are the common delivery channels of this continuum of care, but the evidence base from low- and platform. middle-income countries (LMICs) is far less robust. The Other interventions are best delivered by targeting a chapter includes evidence from HICs and LMICs; iden- particular community setting or group in the commu- tified best practice and good practice strategies are based nity that shares a certain purpose. Community delivery on the best available evidence from both. channels include schools, workplaces, and neighbor- hoods and community groups. Populationwide and community-level interventions POPULATION-LEVEL PLATFORM often require coordinated efforts among different sec- Populationwide interventions are rarely evaluated tors, such as health, education, social development, using the gold standard of randomized control trials labor, and criminal justice systems. (RCTs). More commonly used evaluation methods and A third platform for delivering interventions—the approaches are quasi-experimental natural experiments, health care system—is the subject of chapter 11 in this with before-and-after data obtained from archival analy- volume (Shidhaye, Lund, and Chisholm 2015). sis of official statistics or surveys, and comparisons with populations that have not been exposed to the interven- tion, where possible. Best-practice interventions were KEY FINDINGS identified on the basis of existing quasi-experimental Populationwide and community-level platforms are evidence from LMICs and evidence of cost-effectiveness important for promotion and prevention interven- (at least from HICs). Good-practice interventions were tions; identification and case detection; and, to a lesser identified on the basis of emerging evidence in LMICs degree, treatment, care, and rehabilitation. The evidence and assumptions that laws and regulations that are in Corresponding author: Inge Petersen, University of KwaZulu Natal, Durban, Psychology, School of Applied Human Sciences, South Africa, peterseni@ukzn.ac.za. 183 Table 10.1 Matrix of Best-Practice and Good-Practice Interventions Identification and case Treatment, care, Delivery platform Promotion and primary prevention detection and rehabilitation Population • Legislation and regulation • Laws and regulations to reduce demand for • Mental health alcohol use: taxes laws and • Laws and regulations to reduce demand regulations that for alcohol use; enforcement of BAC limits, are in line with advertising bans, and minimum ages the best practice and human rights • Laws and regulations to restrict access to standards means of self-harm and suicide • Child protection laws • Laws and regulations promoting healthy lifestyles, for example, tobacco control • Laws and regulations to promote improved control of neurocysticercosis • Information and awareness • Mass public awareness campaigns Community • Workplace • Integrating mental health promotion strategies, such as stress reduction and awareness of alcohol and drug misuse, into occupational health and safety policies • Schools • Universal and targeted SEL programs for • Identification and case vulnerable children detection in schools of • Awareness programs children with MNS disorders • Neighborhood and • Parenting programs during infancy • Training of gatekeepers, community groups • Early childhood enrichment and preschool including community health educational programs workers, police, and social workers, in identification of • Parenting programs for children ages 2–14 MNS disorders, including years self-harm Note: Interventions in red indicate best practice; Interventions in black indicate good practice. BAC = blood alcohol concentration; MNS = mental, neurological, and substance use; SEL = social and emotional learning. line with human rights standards would be protective. Legislation and Regulations for Promotion and Additional interventions were identified on the assump- Primary Prevention tion that addressing the known determinants of MNS Reducing Harmful Alcohol Use disorders should promote mental health and lead to a The prevention of harmful alcohol use in adults provides reduction in MNS disorders, but these interventions were benefits across diseases. It can help prevent the develop- not recommended as good practice, given the lack of ment of alcohol use disorder and unipolar depression, as evidence of their effectiveness. The thorough review in well as other chronic diseases, such as cardiovascular dis- this volume of the available evidence of the most effec- ease, diabetes, and cirrhosis of the liver, and it can reduce tive and cost-effective interventions for the respective the risk of contracting human immunodeficiency virus disorders was used as the evidence base, supplemented (HIV). It can also help with the prevention of accidental by a desk review of the best evidence where necessary and intentional injuries or death (Rehm and others 2006). (see online annex table 10A.) For further information on Evidence from HICs and LMICs indicates that the the cost-effectiveness of the mental health interventions most cost-effective strategy for reducing alcohol con- referenced in this chapter, see chapter 12 in this volume sumption is increased taxation or pricing of alcohol (Levin and Chisholm 2015). products, followed by bans on alcohol advertising, 184 Mental, Neurological, and Substance Use Disorders restrictions on access to alcohol, and enforcement of MNS disorders in children and adults in LMICs are drinking-and-driving legislation (see chapter 7 in this included here based on evidence of the determinants, volume, Medina-Mora and others 2015; and chapter 12 in as well as emerging but promising evidence of the effec- this volume, Levin and Chisholm 2015). However, raising tiveness, of the recommended interventions in LMICs. taxes is less effective in countries with lower levels of Prenatal development and infancy is a particularly alcohol consumption; other targeted interventions, such vulnerable period for the development of a wide range as enforcing drunk driving legislation and brief screening of MNS disorders. Possible interventions are suggested, and intervention, are more effective. Regulations may based on evidence of the determinants of healthy devel- also be less effective in countries where alcohol can be opment and MNS disorders during this stage. The easily acquired through the unregulated or black market assumption is that addressing these determinants would or home brews (Rehm and others 2006). The cost of scal- lead to a reduction in MNS disorders (Petersen and ing up these interventions has been estimated for LMICs; others 2014). However, the following interventions are implementation of a package of population-based not recommended as good practice, given the lack of demand reduction measures amounts to no more than evidence of effectiveness in LMICs: US$0.25 per person (WHO 2011a). • Regulations to improve obstetric and perinatal care Restricting Access to Means of Suicide to prevent birth trauma, given its association with Suicide is one of the leading causes of premature deaths physical and mental disabilities, notably epilepsy (see worldwide. Globally, the ingestion of pesticides, hanging, chapter 5 in this volume, Thakur and others 2015) and use of firearms are among the most common meth- • Regulations to strengthen prenatal and postnatal ods (WHO 2014). Regulations restricting access to com- immunization programs to prevent infectious dis- mon, regional-specific, lethal means of suicide—such eases, such as HIV, as well as rubella and toxoplasmo- as firearm control legislation, restrictions on pesticides, sis, which can impact cognitive development and detoxification of domestic gas—have been shown • Regulations to increase access to micronutrients to decrease rates of suicide in HICs and LMICs (van for vulnerable populations, including salt iodization der Feltz-Cornelis and others 2011). Means restrictions programs to prevent iodine deficiency, which is asso- require an understanding of the common methods used ciated with mental retardation during early infancy in different sectors of societies and countries, as well as • Regulations to promote folic acid food fortification the cooperation of different sectors (WHO 2014). The and selective protein supplementation programs to impact of the introduction of pesticide regulations on promote healthy cognitive development. the reduction of suicides in Sri Lanka provides a case study of how this strategy has been effectively applied in During childhood, maltreatment is a risk factor for LMICs (box 10.1). Cost-effectiveness modelling of such a the development of MNS disorders. Some promising pesticide ban in the Indian context has been undertaken evidence from LMICs indicates that the enactment of for this volume (Nigam and others 2015). child protection laws for children living outside the family has health and safety benefits for these children Other Multisector Legislative and Regulatory (Fluke and others 2012), although further research to Interventions assess the benefits for children within their families of Other legislative and regulatory interventions to pro- origin is indicated. Such laws are, nevertheless, con- mote mental health and prevent the development of sidered as good practice. Emerging evidence indicates Box 10.1 Pesticide Regulations as an Intervention to Reduce Suicide: Sri Lanka Self-poisoning with pesticide is the most common Organization toxicity Class 1 pesticides in 1995 and method of suicide in Sri Lanka, accounting for two- the banning of endosulfan, a Class II toxicity pesti- thirds of suicide deaths. The suicide rate in Sri Lanka cide, in 1998, the suicide rate halved from 1996 to reached a peak in 1995 at 47 deaths per 100,000 2005, with a reduction of 19,769 suicides, compared population. With the banning of all World Health with 1986–95 (Gunnel and others 2007). Population and Community Platform Interventions 185 the protective influence of conditional cash transfers on the formulation of national strategies, national laws, against poor cognitive and behavioral outcomes in human rights provisions, primary care integration and vulnerable children (Fernald and Gunnar 2009; Lund treatment guideline formulation, information systems, and others 2011). Further research is, however, required and suicide prevention (Hess and others 2004; Pinfold before recommendations can be made. and others 2003; Swartz and others 2010; Thornicroft Other multisector laws and regulations to promote 2000; Watson and others 2004; WHO 2008, 2011b, mental health and prevent MNS disorders in children 2012, 2013a); these issues are closely related to the and adults include the following: growing field of implementation science (Tansella and Thornicroft 2009). • Restricting access to illicit drugs through laws and The WHO QualityRights Project has a toolkit to help regulations preventing their sale, possession, and use. countries assess and implement strategies to meet key However, the evidence on the effectiveness of such standards in inpatient and outpatient mental health and interventions in LMICs remains insufficient for them social care facilities. These strategies are in alignment to be recommended as good practice (see chapter 6 in with the International Convention on the Rights of this volume, Degenhardt and others 2015). Persons with Disabilities (WHO 2012). • Legislation to reduce traumatic brain injury and the The objectives of the WHO QualityRights Project are consequent risk of epilepsy, such as through mandatory as follows: use of helmets by motorcyclists. Evidence as to the effectiveness of this strategy for reducing epilepsy in • Improving the quality of care and human rights con- LMICs is still required before it can be recommended ditions in mental health and social care facilities as good practice (see chapter 5 in this volume, Thakur • Changing attitudes and building capacity in service and others 2015). users, families, and health workers to understand and • Regulations to improve control of neurocysticercosis promote human rights and recovery (a common cause of epilepsy in LMICs) through • Promoting the involvement of people with mental deworming of humans, vaccination of pigs, improved disabilities in advocacy work sanitation, better meat inspection, and improved • Reforming national policies and legislation to be pig farming. Promising evidence is emerging from in alignment with best-practice and international Honduras that these interventions can reduce epi- human rights standards. lepsy in hyperendemic populations (Medina and others 2011), and they are recommended as good Even without an evidence base to support such an practice. initiative, it is reasonable to assume that up-to-date • Legislation against domestic violence as possible inter- mental health laws and regulations that are in line vention, given that risk factors for common mental with human rights standards, as outlined by the WHO disorders in women include interpersonal violence QualityRights Project, should be readily accepted as (Patel and others 2010). Some limited evidence good practice. from HICs suggests that such legislation reduces the chances of family or intimate partner violence (Dugan 2003). However, evidence from LMICs is Information and Awareness Campaigns for Promotion required before it can be recommended as good and Primary Prevention practice. Information and public awareness campaigns employ • Regulations promoting healthy lifestyles, given that broad strategies and messages to promote mental health risk for dementia in later life includes cardiovascular literacy—defined as knowledge and beliefs about mental conditions. These interventions are recommended as disorders to aid their recognition, management, and good practice (see chapter 5 in this volume, Thakur prevention (Jorm 2012)—as well as reduce stigma and and others 2015). discrimination. The campaigns disseminate informa- tion, for example, about signs and symptoms, locations Protecting Persons with MNS Disorders where people may receive help, facts and figures about The utility of national or state regulations and legis- prevalence and risk factors, and evidence to combat lation and their effects on mental health promotion, stigmatizing beliefs. Multifaceted techniques to supple- prevention, treatment, care, and rehabilitation are more ment traditional media outlets via lobbying of impor- fully covered by policy guidelines than by evidence- tant stakeholder groups, facilitating grassroots activism, based literature. The World Health Organization and mobilizing the public at popular events seem to be (WHO) and others have produced detailed guidance the most effective for encouraging prosocial behaviors, 186 Mental, Neurological, and Substance Use Disorders such as stigma reduction and help-seeking (Thornicroft regional efforts through the Open the Doors program and others, 2015). (http://www.openthedoors.com/english/index.html) to Most information and awareness programs rep- reduce stigma, specifically in relation to people with resent low-intensity interventions aimed at large num- schizophrenia (Warner 2005); however, evaluation of the bers of people, often through print media, recordings, program in LMICs is lacking. General lessons emphasize radio, television, cinema, mobile phones, and the involving patients and caregivers in the development Internet (Andreasen 2006; Clement and others 2013). and evaluation of anti-stigma work, establishing a local Several examples of large-scale national efforts, and network of committed institutions and individuals, and a growing evidence base, demonstrate their effective- addressing stigma within health care through incorpo- ness in increasing knowledge about and recognition rating anti-stigma efforts into MNS services (Sartorius of MNS disorders (Jorm, Christensen, and Griffiths 2010; Stuart 2008). 2005), improving attitudes (Dunion and Gordom 2005; The experiences and consequences of stigma vary Evans-Lacko, Malcolm, and others 2013), and reducing across countries and cultures. Development and evalu- discrimination in a cost-effective manner (Corker ation of anti-stigma interventions that are tailored and and others 2013; Evans-Lacko, Henderson, and oth- locally developed in LMICs are needed (Thornicroft and ers 2013; Henderson and others 2012; McCrone and others 2015; Yang and others 2007). others 2010; Thornicroft and others 2010; Thornicroft Online interventions may represent a low-cost and others 2014). Although information and awareness method of reaching individuals in LMICs. Many websites programs often cover a broad range of MNS disor- provide information on MNS disorders, but few studies ders, most focus on mental rather than neurological have performed evaluations. One intervention in LMICs disorders. One RCT from Hong Kong SAR, China, looked at whether an anti-stigma computer program however, showed that exposing individuals to infor- would improve knowledge and attitudes and reduce mation about dementia through vignettes led to a social distance among university students in the Russian statistically significant reduction in stigma (Cheng and Federation (Finkelstein, Lapshin, and Wasserman 2008). others 2011). Students were randomized to one of three groups: a Several recent systematic reviews of the literature have computer program group, a reading group, or a control examined the effectiveness of various types and compo- group. Participants were evaluated at baseline, immedi- nents of anti-stigma interventions, including awareness ately following the intervention, and six months later. programs aimed at the general public in HICs. A system- Immediately following the intervention, knowledge, atic review that focused on mass media strategies showed attitudes, and social distance improved among students that such interventions may reduce prejudice, although in the reading and computer program groups. At the fewer studies have investigated the effects of media six-month follow-up, the reading group showed some strategies on discrimination (Clement and others 2013). improvement in attitudes; all stigma outcomes were A recent review by Corrigan and others (2012) examined significant in the computer program group. anti-stigma approaches specific to mental illness and Based on sufficient evidence from HICs and emerg- incorporated elements of education, protest, or contact. ing promising evidence from LMICs, mass public In-person contact interventions yielded the greatest effect awareness campaigns and, to a lesser extent, more tar- in adults; education was most effective among adoles- geted programs are recommended as good practice. For cents. One challenge is to deliver these types of interven- stigma reduction, in particular, more research, generat- tions on a mass scale to the public. Some evidence, using ing evidence of the effectiveness of social contact among a pre-post research design, demonstrates the feasibility the adult population and education-focused interven- and effectiveness of achieving positive intergroup contact tions among adolescents is recommended for HICs and through large public events (Evans-Lacko and others LMICs. In LMICs in particular, more information is 2012). Moreover, evidence supports the effectiveness of needed about how best to tailor existing interventions to virtual contact via film or video; these types of interven- local cultures, using available resources, and how best to tions could be more cost-effective (Clement and others reach key stakeholders—both targets and instigators of 2012), a finding that could be especially relevant for stigma—in these settings. low-resource settings. For example, mobile phones and other technologies in LMICs might be explored as ways to increase access to information and awareness. COMMUNITY-LEVEL PLATFORMS Evidence of the effectiveness of mass information Studies on interventions at the community-level plat- programs in LMICs is limited. In 1996, the World form in LMICs are limited; best-practice interventions Psychiatric Association initiated several national and were identified from the chapters on MNS disorders in Population and Community Platform Interventions 187 this volume (chapter 6 in this volume, Degenhardt and Limited but promising evidence from LMICs of the others 2015; chapter 8 in this volume, Scott and others effectiveness of primary prevention and promotion is 2015) and supplemented by a desk review of available provided by the SOLVE training package, developed by systematic reviews and trials in LMICs. Many of these the International Labour Organization (Probst, Gold, interventions have a prevention and promotion focus, and Caborn 2008). This training of trainers program and the Assessing Cost-Effectiveness (ACE) prevention provides human resource managers, trade unions, framework (Carter and others 2000) was used to eval- employers, and health professionals with the necessary uate effectiveness. The ACE grading system provides knowledge and skills for integrating mental health pro- a single framework for the evaluation of evidence on motion strategies, such as stress reduction and awareness clinical, public health, and behavioral interventions. of alcohol and drug misuse, into occupational health and safety policies and workplace action programs. The • Sufficient evidence. There is evidence of effectiveness SOLVE program has been implemented in several coun- as demonstrated by at least one systematic review of tries, including China, India, Kenya, Malaysia, Namibia, RCTs, as well as several good-quality RCTs or several the Philippines, South Africa, Sri Lanka, Swaziland, and high-quality pseudo-RCTs using alternate allocation Zambia. Preliminary evaluation of the original SOLVE or another method, or non-RCTs with comparative program, with 268 participants in seven countries, using groups to exclude chance. a pre-post test design, produced encouraging findings • Limited evidence. The effect is probably not due to concerning knowledge gains following training (Probst, chance, but bias cannot be ruled out as a possible Gold, and Caborn 2008). However, more rigorous studies explanation for the effect. We have classified this evi- are needed to determine the long-term effectiveness and dence as promising. sustainability of this program across diverse workplace • Inconclusive evidence. There is no evidence of sys- settings in LMICs. In view of the limited but promising tematic reviews or RCTs, although there may be a evidence of the feasibility and impact of this program, few poor-quality pseudo-randomized non-RCTs with such integrated mental health strategies in the workplace comparative groups or cohort studies. are considered as good practice. Best-practice interventions were identified on the basis Identification and Case Detection of two criteria: Evidence on the identification and case detection of MNS disorders in the workplace could only be sourced from • Evidence of their effectiveness based on sufficient HICs. An evaluation of the APPRAND program in France evidence from LMICs, using the ACE framework, as provided evidence on individuals on sick leave who were well as their cost-effectiveness in HICs. screened by company health physicians and identified as • Evidence of their feasibility in relation to cultural having anxiety and depressive disorders and who received acceptability and capacity for scale-up in resource- an awareness-raising and referral intervention. Those constrained settings in LMICs. individuals displayed higher remission and recovery rates, compared with individuals in other centers who Good-practice interventions were identified on the were not screened and who did not receive the inter- basis of sufficient evidence of their effectiveness in HICs vention (Godard and others 2006). Positive effects have and/or promising evidence of their effectiveness in also been reported for a mental health first aid course in LMICs, using the ACE framework. Australia that included training in screening for mental disorders (Kitchener and Jorm 2004). For neurological disorders, positive outcomes have Workplaces been reported in the United States for migraine and Promotion and Primary Prevention headache management programs that have included Workplace settings provide an ideal delivery channel screening questionnaires and educational initiatives. for promotion and prevention interventions for adults. These interventions resulted in an increase in the number Evidence from HICs indicates that individual- and of participants seeking help from physicians, an improve- organization-level interventions improve and maintain ment in headache symptoms, a reduction in absenteeism mental health in the workplace. These interventions include among those affected, and a reduction in the cost burden screening and cognitive behavioral therapy (CBT) for pre- to employers (Page and others 2009; Schneider and oth- clinical symptoms of depression and anxiety to prevent the ers 1999). No evidence for screening for MNS disorders onset of these disorders (Nytro and others 2000; WHO in the workplace could be sourced from LMICs, and these 2000). However, the evidence base from LMICs is sparse. interventions are not yet recommended. 188 Mental, Neurological, and Substance Use Disorders Treatment, Care, and Rehabilitation study that was performed in rural secondary schools Interventions for the treatment, care, and rehabilitation in Pakistan could be sourced. The intervention, led of MNS disorders in the workplace have been effective by health care professionals, involved a short training in HICs. For people with common mental disorders, course for teachers, with a co-constructed educational individual therapies rather than organizational inter- program of lectures and several participatory activities. ventions have been the most effective, in particular, CBT The study used an RCT evaluation and assessed changes (BOHRF 2005; Hill and others 2007; Seymour 2010), in knowledge and attitudes four months after the start of either face to face or more questionably via computer the program. Improvements were noted among school- software (Grime 2004; van der Klink and others 2001). children, parents, friends, and neighbors. In the control To a lesser extent, exercise and relaxation interventions, group, there were improvements only among schoolchil- such as aerobic or meditation sessions, have been ben- dren and their friends (Rahman and others 1998). eficial (Graveling and others 2008). Independent case For neurological disorders, only studies in HICs management by third-party specialists, such as labor could be sourced. Hip Hop Stroke is an example of an experts or employment advisors, has shown a posi- information and awareness program for children (ages tive impact on people with common mental disorders 8 to 12 years) from schools in a high-risk stroke neigh- when combined with psychological therapies, such as borhood in the United States. Following the program, CBT (Seymour 2010). Multimodal interventions may the children showed improved knowledge of stroke be more effective than single interventions (BOHRF symptoms and behavioral intent to call 911 (Williams 2005). With respect to severe mental disorders (SMDs), and others 2012). Given that promising evidence is sufficient evidence from HICs indicates the benefits of emerging on the positive impact of information and supported employment, for example, individual place- awareness interventions in schools in LMICs, these ment and support, in helping people obtain competitive programs are recommended as good practice. Further employment (Crowther and others 2001; Dickson and research on the impact of such interventions in schools Gough 2008; McDaid 2008). is needed. For neurological disorders, a few studies have shown positive effects, although with mixed results, for educa- Social and Emotional Learning Interventions. Studies tional and physical programs implemented in workplace from HICs and LMICs indicate that life skills pro- settings in Finland and Italy to reduce headaches and grams to build socioemotional competencies in children neck and shoulder pain (Mongini and others 2012; Rota and adolescents (social and emotional learning [SEL] and others 2011; Sjögren and others 2005). Furthermore, programs) can improve social and emotional function- an RCT in South Africa found that a workplace inter- ing and academic performance in exposed children. The vention consisting of workability assessments and work- programs also reduce risk behavior, when combined place visits was able to facilitate return to work for stroke with reproductive and sexual health and substance use patients (Ntsiea 2013). education. Systematic reviews from HICs show that uni- Overall, evidence from LMICs for the treatment, care, versal SEL interventions in primary and post-primary and rehabilitation of MNS disorders in the workplace is schools promote children’s social and emotional func- insufficient for recommendations to be made. Further tioning and academic performance in the long term research is recommended on the effectiveness of training (Durlak and others 2011; Lister-Sharp and others 1999; in first-level management of acute symptoms, partic- NICE 2009; Tennant and others 2007; Weare and Nind ularly CBT, for anxiety or depression (possibly com- 2011; Wells, Barlow, and Stewart-Brown 2003). bined with independent case management); supported In relation to substance abuse in particular, school- employment for people with SMDs; and educational, based interventions that target social skills more broadly physical, and return-to-work interventions for neuro- in younger children have been found to have a greater logical disorders. positive effect than in high school–age children (see chapter 6 in this volume, Degenhardt and others 2015). Evidence from HICs also indicates that interventions Schools that employ a whole-school approach are most effective Promotion and Primary Prevention and have helped to reduce bullying. In the whole-school Information and Awareness. Examples of robust eval- approach, SEL is supported by a school ethos and a phys- uations of broad information and awareness inter- ical and social environment that is health-enabling and ventions addressing MNS literacy are more available involves staff, students, parents, the school environment, in HICs (Pinfold and others 2003; Swartz and others and the local community. Bullying has been identified as 2010; Watson and others 2004). In LMICs, only one a risk factor for the development of psychiatric disorders Population and Community Platform Interventions 189 in bullies and their victims (see chapter 8 in this volume, as age and gender, as well as contextual variables, such Scott and others 2015). as conflict, displacement, and family functioning (Tol A systematic review (Barry and others 2013) and and others 2014), and may be better suited for children other studies (De Villiers and van den Berg 2012; with less severe risks and difficulties (Fazel and others Mueller and others 2011; Smith and others 2008; Srikala 2014). Box 10.3 describes a case study of the impact of and Kishore 2010) provide sufficient evidence of the a classroom, community, and camp–based intervention beneficial effects of universal SEL programs in LMICs. for children in economies at war and with complex These interventions can be feasibly delivered by teachers emergencies. The intervention was taken to scale in the and school counselors through the integration of SEL West Bank and Gaza (Khamis, Macy, and Coignez 2004). into life orientation curricula, as demonstrated by the Economic analyses from HICs indicate that SEL HealthWise program in South Africa (Smith and others interventions in schools are cost-effective, resulting 2008) (box 10.2). However, the quality of implementa- in savings from better health outcomes, as well as tion and contextual issues can affect the impact of SEL reduced expenditures in the criminal justice system interventions; teacher training, support, and supervision (McCabe 2007). are needed, as is attention to the school environment The cost of implementing school-based SEL inter- (Caldwell and others 2012), suggesting that integration ventions in LMICs has not yet been estimated. An into a whole-school approach is preferred. attempt is made in chapter 12 in this volume (Levin For high-risk children, targeted and indicated inter- and Chisholm 2015) on the basis of a psychosocial ventions that promote coping skills, resilience, and intervention to prevent depression in adolescents ages cognitive skills training have helped prevent the onset 12 to 16 years in Mauritius (Rivet-Duval, Heriot, and of anxiety, depression, and suicide in HICs (Clarke and Hunt 2011). The findings suggest that school-based SEL others 1995; Jaycox and others 1994; Shucksmith and interventions represent a low-cost strategy to promote others 2007). Several RCTs of targeted interventions adolescent mental health. Universal and targeted school- for vulnerable children have been conducted in LMICs based SEL interventions are considered as best-practice (Fazel and others 2014). Some classroom-based inter- interventions for LMICs. ventions (CBIs) for vulnerable children, especially those orphaned by HIV or living in areas of conflict, have Identification and Case Detection improved general psychological health and coping (Ager Many MNS disorders have their onset during childhood and others 2011; Jordans and others 2010; Khamis, Macy, and adolescence, and these early difficulties are likely to and Coignez 2004; Qouta and others 2012). However, be present in the school context. Teachers have a crit- these effects are contingent on individual variables, such ical role in identifying emerging problems and taking Box 10.2 The HealthWise Program in South Africa HealthWise combines leisure, life skills, and sexual- demonstrated that HealthWise had a moderately ity education into a 12-lesson program for students positive effect on alcohol use. It was also effective in grade eight, with six booster sessions in grade in increasing awareness of condom availability and nine delivered by teachers during life orientation, perceived condom self-efficacy. The program is with the aim of reducing health risk behaviors. The being expanded to 56 schools in the Cape Town lessons cover socio-emotional skills building, such area to assess the effects of fidelity issues, namely, as decision making, self-awareness, and anxiety and enhanced teacher training; enhanced teacher sup- anger management, as well as the positive use of free port, structure, and supervision; and enhanced time and attitudes, knowledge, and skills building school environment on outcomes. to reduce substance use and sexual risk behaviors. Source: Caldwell and others 2012. An efficacy trial involving 2,383 participants from a low-income community in Cape Town 190 Mental, Neurological, and Substance Use Disorders Box 10.3 Classroom, Community, and Camp–Based Intervention in the West Bank and Gaza Classroom, community, and camp–based inter- and girls (ages 6–11 years), as well as in adolescent vention provides structured expressive-behavioral girls (ages 12–16 years), enabling them to func- group activities over 15 sessions to reduce traumatic tion as other children would in relation to family, stress reactions and strengthen children’s resiliency school, and peers. However, this effect was not the to cope with the stress of ongoing violence and case with adolescent boys (ages 12–16 years), who trauma. The program was delivered by trained demonstrated an increased tendency to use avoid- school counselors and other social workers to more ance of cognitions and feelings as a defense mecha- than 100,000 children in the West Bank and Gaza. nism, which may relate to their greater exposure to A randomized control trial involving 664 children violence. ages 6–16 years found that the program improved psychological functioning and coping in young boys Source: Khamis, Macy, and Coignez 2004. Box 10.4 Teacher Training Program, Brazil An exploratory study in São Paulo, Brazil, tested not initially respond correctly to the vignettes, the effectiveness of an educational strategy to build researchers found at least 50 percent had learned teachers’ capacity to identify students with possible to identify and make referrals of problematic cases mental health problems and subsequently make following the training, and 60 percent learned to appropriate referrals. Teacher training involved identify normal adolescent behaviors. The study two two-hour sessions that included a lecture suggests that brief training can increase teachers’ followed by theoretical and practical exercises. capacity to identify mental health problems and Teachers were evaluated on their ability to identify make appropriate referrals, especially among those and refer students with mental health problems in who initially struggled to do so. a hypothetical vignette scenario. When assessing responses specifically among teachers who did Source: Vieira and others 2014. appropriate action. RCTs from HICs provide evidence The intervention was associated with improvements in for training in indicated screening of developmental knowledge, attitudes, and recognition of MNS disor- and behavioral disorders in schools. Programs such as ders (Eustache, Becker, and Wozo 2014). In Chandigarh Mental Health First Aid for High School Teachers have city, India, a one-off educational intervention package been tested using a cluster RCT (Jorm and others 2010). improved teachers’ knowledge, attitudes, and skills Data from LMICs are limited. However, evidence regarding epilepsy immediately after the intervention, supports the feasibility and reliability of identify- and at the three-month follow-up. However, it was ing and assessing MNS disorders in primary and noted that further workshops would likely be required secondary school students (Becker and others 2010a, for long-term benefit (Goel and others 2014). 2010b; Opoliner and others 2013; Vieira and others Given sufficient evidence from HICs, as well as 2014) (box 10.4). In Haiti, a 2.5 day training program emerging promising evidence from LMICs, the identi- for secondary school teachers focused on recogniz- fication and case detection in schools of children with ing, responding to, and referring students at risk for MNS disorders are recommended as good practice. MNS disorders following the earthquake in 2010. Further research adapting and developing, validating, Population and Community Platform Interventions 191 and piloting screening tools that are culturally sensi- young people with high depression scores. The analysis tive, user friendly, and easy to administer in LMICs is showed no clinically significant difference between the proposed. intervention and control groups and no evidence of effect modification by severity of symptoms (Araya and Treatment, Care, and Rehabilitation others 2013). There is sufficient evidence of the effective treatment A few CBI trials have incorporated cognitive behav- and management of some MNS disorders in schools ioral techniques and creative expressive elements to help in HICs. A meta-analysis that examined the effective- children with depressive, anxiety, and post-traumatic ness of various types of school-based CBT for young stress disorder (PTSD) symptoms in complex emer- people with anxiety and depression showed significant gencies in LMICs (Jordans and others 2010; Tol and reductions in symptoms overall (Mychailyszyn and others 2008; Tol and others 2012; Tol and others 2014). others 2012). School-based interventions for attention- The emerging evidence on the effectiveness of treatment deficit hyperactivity disorder (ADHD) have been found of PTSD and depressive symptoms is inconsistent; CBI to be promising in younger children but less so for has more consistent prevention benefits, particularly adolescents; these interventions lack robust long-term when the risks are less severe. Accordingly, CBI cannot program effectiveness data, as well as cost-effectiveness be recommended for treatment of these conditions in data (Kutcher and Wei 2012). Effective ADHD interven- conflict-affected children (Fazel and others 2014). Given tions that improve academic and behavioral outcomes the equivocal evidence from LMICs, further research involve contingency management, academic interven- generating positive outcomes for treatment, care, and tion, and cognitive-behavioral interventions (DuPaul, rehabilitation for children with MNS disorders in schools Eckert, and Vilardo 2012). For neurological disorders, is required before recommendations can be made. a classroom-based headache prevention program in Germany found a small but significant reduction in reported tension-type headaches seven months follow- Neighborhood and Community Groups ing the intervention (Albers and others 2015). Primary Prevention and Promotion Evidence from HICs also indicates that children An array of primary prevention and promotion inter- with emotional and behavioral disorders benefit from ventions is delivered at the neighborhood level or classroom environments that are predictable and through community groups. These interventions include consistent, with clear structures and rules; such set- programs on early childhood enrichment and preschool tings are associated with improved classroom and peer educational programs, community-based parenting, and behavior and enhanced learning (Simpson, Peterson, gender and economic empowerment interventions. and Smith 2011). A classroom strategy focused on punishment is likely to increase aggression and other Early Childhood Enrichment and Preschool behavioral problems (Kennedy and Jolivette 2008). Educational Programs. Robust evidence from HICs Some research indicates the benefits of academic demonstrates the effectiveness and cost-effectiveness of supports; however, there are significant limitations early childhood enrichment and preschool educational in the current evidence base, as many of these studies programs on social and emotional well-being, cog- used single-subject designs and lacked measures of nitive skills, problem behaviors, and school readiness fidelity, that is, whether the intervention was imple- (Anderson and others 2003; Nelson, Westhues, and mented as intended; most did not include minorities MacLeod 2003; Tennant and others 2007). There is (Mooney and others 2003). Interventions that use also evidence of long-term effects on school attain- direct instruction, peer tutoring, and behaviorally ment, social gains, and occupational status in HICs based procedures—such as time delay prompting, trial (Schweinhart and others 2005). and error, and differential reinforcement—hold prom- The evidence from LMICs is promising (Aboud ise (Rivera, Al-Otaiba, and Koorland 2006). 2006; Cueto and others 2009; Kagitcibasi, Sunar, and Evidence from LMICs for treatment, care, and reha- Bekman 2001; Kagitcibasi and others 2009). Evidence bilitation for children with MNS disorders is limited and of the long-term benefits of early childhood enrichment equivocal. An RCT of a universal school-based interven- and preschool educational programs is provided by tion for reducing depressive symptoms was conducted the Turkish early childhood enrichment project. Long- in Chile. It used CBT techniques delivered by non- term follow-up of a cohort of 131 participants found specialists and comprised 11 one-hour weekly sessions that children who received a home-based educational and two booster classroom sessions. Although it was a intervention, preschool education, or both, achieved universal intervention, the study analyzed subgroups of higher educational attainment and occupational status 192 Mental, Neurological, and Substance Use Disorders and obtained employment earlier that those partic- Hansson and Markstrom 2014; Krameddine and others ipants who received neither (Kagitcibasi and others 2013; Teller and others 2006; Watson and others 2008). 2009). These interventions are therefore considered to Given that community health workers may operate from represent good practice. health centers or utilize a home visitation program, these interventions may overlap with interventions delivered Parenting Interventions. There is sufficient evidence at the first-level facility platform described in chapter 11 from LMICs of the effectiveness and feasibility of par- in this volume (Shidhaye, Lund, and Chisholm 2015). enting programs to enhance mother-child interaction With respect to neurological disorders, research from during infancy for these interventions to be considered HICs suggests that trained community health workers good practice (Cooper and others 2009; Jin and others can facilitate early detection of dementia in resource- 2007; Mejia, Calam, and Sanders 2012; Rahman and poor communities (Han and others 2013). Moreover, others 2009; Walker and Chang 2013; Wendland-Carro, if screening leads to early intervention within a year Piccinini, and Millar 1999). Many interventions are of detection, it could be associated with cost savings delivered at health centers or utilize a home visitation through reduced health care costs in the long run program and may overlap with interventions delivered (Saito and others 2014). Mental health first aid training at the first-level facilities described in chapter 11 in this of community members generally has been found to volume (Shidhaye, Lund, and Chisholm 2015). increase knowledge, reduce stigma, and increase help- The effectiveness of community parenting programs seeking behavior in HICs. Although mental health first for the prevention of internalizing and externalizing dis- aid training is being rolled out in several LMICs, evi- orders in children who are preschool and school age has dence of effectiveness is still lacking (Jorm and others been demonstrated in HICs (e.g., Kaminski and others 2004). Given sufficient evidence from HICs, as well as 2008), with promising evidence from LMICs (Fayyad emerging promising evidence from LMICs, for training and others 2010; Oveisi and others 2010; Vasquez and non-mental health workers and community members others 2010; Wendland-Carro, Piccinini, and Millar in identification and case detection, it is recommended 1999); these are also considered as good practice. as good practice. Further research on the impact of such interventions on increasing access to mental health care Gender Equity and Economic Empowerment in LMICs is required. Interventions. A growing body of research indicates the feasibility and benefits for vulnerable adolescents and Treatment, Care, and Rehabilitation adults of gender equity and economic empowerment Policy shifts to deinstitutionalize and decentralize programs in LMICs (Balaji and others 2011; Brady and care in many LMICs are heightening the need for others 2007; Jewkes and others 2008; Kermode and oth- community-based treatment and rehabilitation for ers 2007; Kim and others 2009; Pronyk and others 2006; mental disorders. These interventions are generally deliv- Ssewamala, Han, and Neilands 2009). For poor people ered through health care platforms and are described in in Sub-Saharan Africa, microfinance (micro-credit and detail in chapter 11 in this volume (Shidhaye, Lund, and microsavings) schemes that incorporate gender empow- Chisholm 2015). erment, health, and educational training components are more effective in terms of mental health benefits over standalone programs (Lund and others 2011; Stewart CONCLUSIONS and others 2010). Further evidence is, however, required This chapter has reviewed the evidence on population- before these programs can be recommended as good and community-level interventions that improve mental practice. health in LMICs. Identification and Case Detection Mental health first aid training at the community level involves training community members to identify when a Population-Level Interventions person is developing a mental disorder, is suicidal, or is in Interventions at the population platform have a broad crisis; to know how to manage the situation; and to know reach, promoting and protecting the mental health of where to refer the person appropriately (Jorm 2012). the entire population through legislation, regulations, Evidence for feasible and effective identification and public campaigns. Legislation and regulations to training programs for non-mental health workers is par- control alcohol demand can reduce consumption in ticularly robust for police officers and community health LMICs at minimal cost; and taxation on alcohol prod- workers in HICs and LMICs (Chibanda and others 2011; ucts is recommended as best practice. Population and Community Platform Interventions 193 Laws and regulations restricting access to lethal means Stronger evidence exists in LMICs for schools as a of suicide that are region specific can reduce suicide rates delivery channel for interventions across primary preven- in LMICs and are also recommended as best practice. tion and promotion and identification. There is robust Mental health laws aligned with international standards for evidence of life skills training in schools to promote social human rights protection are recommended as good prac- and emotional competencies. This is recommended as best tice on the assumption that they are likely to help to curb practice. There is promising evidence for the identification violations in mental health and social care facilities. Child of mental disorders in schools, which is recommended as protection laws and improved control of neurocysticerco- good practice. sis are recommended as good practice, given the emerging Emerging promising evidence supports the delivery evidence of their health and safety benefits in LMICs. of neighborhood and community group interven- Legislative changes are relatively low cost, but they can tions in LMICs. In primary prevention and promotion be difficult to implement, with adaptation and implemen- programs, parenting programs, particularly during tation requiring the buy-in and cooperation of multiple infancy, are recommended as good practice. Evidence is sectors. With respect to alcohol legislation in particular, emerging on the long-term benefits of early childhood unregulated markets, easy access to home brews, and enrichment and preschool educational programs, and access to the black market in LMICs may limit the success these are recommended as good practice. Emerging of this strategy. LMICs are also likely to encounter oppo- evidence also suggests the mental health benefits of sition from local and international alcohol producers, gender and economic empowerment programs, but is with the latter increasingly targeting emerging markets. still insufficient to recommend as good practice. For Strong political will and advocacy work, within and identification and treatment, care, and rehabilitation, outside governments, are necessary to garner public and the training of gatekeepers to identify people with men- political support for legislation to reduce the demand tal illness is recommended as good practice, based on for alcohol. National and international nongovernmen- emerging promising evidence in LMICs. tal organizations and the media can play an important Many MNS disorders have their onset during child- role. International cooperation and regulation-related hood and adolescence (Kessler and others 2005; WHO legislation to help prevent illicit trade and cross-border 2013b); early difficulties are likely to present at the advertising, promotion of alcohol consumption, and community platform in schools and neighborhoods. sponsorship have been suggested as important, particu- Interventions along the continuum of care described in larly for emerging markets struggling to enter the global this chapter are particularly important to prevent the economy (Casswell and Thamarangsi 2009). onset and reduce the severity of the course of MNS dis- Suicide prevention through restricting access to the orders. However, community-level interventions require means of suicide may encounter challenges in regulating strong intersectoral engagement, as well as buy-in to access to certain means of suicide, such as by hanging or task-sharing. Teachers, social workers, police, community self-immolation, and this may also limit the success of health workers, and community members can provide this strategy. first-line mental health care with sufficient training and For mass information and awareness campaigns for support. To enable collaborative arrangements with dif- promoting mental health literacy and reducing stigma ferent departments, as well as community-based groups, as a public health strategy at the population level, some including nongovernmental organizations, spiritual lead- small-scale but promising evidence from LMICs indi- ers, and traditional healers, Skeen and others (2010) cates the potential effectiveness of mass public awareness suggest the formalization of these arrangements through campaigns; they are recommended as good practice. legislation of intersectoral forums for mental health from the national to the local levels. Such forums can facilitate awareness of mental health as a public health priority in Community-Level Interventions other sectors, illuminate the role these other sectors can Interventions at the community platform have less play, and clarify the roles and responsibilities and referral broad reach but more depth and intensity. This chapter pathways between sectors (Skeen and others 2010). reviewed the evidence for interventions delivered in the Although much attention has historically been paid to workplace, at schools, and in neighborhoods and com- platforms within the health sector for the delivery of men- munity groups. In the workplace, integrating mental tal health services, it is increasingly clear that greater con- health promotion strategies, such as stress reduction and sideration of population- and community-level platforms awareness of alcohol and drug misuse, into occupational is necessary for the delivery of prevention and promotion health and safety policies is recommended as good prac- interventions, as well as for the early identification of tice, based on emerging evidence in LMICs. mental disorders, particularly in children and adolescents. 194 Mental, Neurological, and Substance Use Disorders ANNEX 10A Health of Students in Santiago, Chile: A Randomized Clinical Trial.” JAMA Pediatrics 167 (11): 1004–10. The annex to this chapter is as follows. It is available at Balaji, M., T. Andrews, G. Andrew, and V. Patel. 2011. “The www.dcp-3.org/mentalhealth. Acceptability, Feasibility, and Effectiveness of a Population- Based Intervention to Promote Youth Health: An • Annex 10A. Evidence of Interventions at the Exploratory Study in Goa, India.” Journal of Adolescent Population- and Community-Level Platforms Health 48 (5): 453–60. Barry, M. M., A. M. Clarke, R. Jenkins, and V. Patel. 2013. “A Systematic Review of the Effectiveness of Mental Health Promotion Interventions for Young People in Low and NOTES Middle Income Countries.” BMC Public Health 13 (1): 835. Disclaimer: Dan Chisholm is a staff member of the World Becker, A. E., J. J. Thomas, A. Bainivualiku, L. Richards, Health Organization. The author alone is responsible for the K. Navara, and others. 2010a. “Adaptation and Evaluation of views expressed in this publication, and they do not necessarily the Clinical Impairment Assessment to Assess Disordered represent the decisions, policy, or views of the World Health Eating Related Distress in an Adolescent Female Ethnic Organization. Fijian Population.” International Journal of Eating Disorders This chapter was previously published in an article by 43 (2): 179–86. doi:10.1002/eat.20665. M. Semrau, S. Evans-Lacko, A. Alem, J. L. Ayuso-Mateos, ———. 2010b. “Validity and Reliability of a Fijian Translation D. Chisholm, O. Gureje, C. Hanlon, M. Jordans, F. Kigozi, and Adaptation of the Eating Disorder Examination H. Lempp, C. Lund, I. Petersen, R. Shidhaye, and G. Thornicroft, Questionnaire.” International Journal of Eating Disorders titled “Strengthening Mental Health Systems in Low- and Middle- 43 (2): 171–78. doi:10.1002/eat.20675. Income Countries: The Emerald Programme.“ BMC Medicine, BOHRF (British Occupational Health Research Foundation). 2015; 13 (79). doi:10.1186/s12916-015-0309-4. . Health Problems: Evidence Review and Recommendations. World Bank Income Classifications as of July 2014 are as London: BOHRF. follows, based on estimates of gross national income (GNI) Brady, M., R. Assaad, B. Ibrahim, A. 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Lee, and others. in Honduras.” Southern Online Journal of Nursing Research 2007. “Culture and Stigma: Adding Moral Experience to 10 (3): 1–25. Stigma Theory.” Social Science and Medicine 64: 1521–35. 200 Mental, Neurological, and Substance Use Disorders Chapter 11 Health Care Platform Interventions Rahul Shidhaye, Crick Lund, and Dan Chisholm INTRODUCTION care platform). Identifying the set of interventions that fall within a particular delivery channel will help Evidence-based interventions often fail to achieve their decision makers to identify potential opportunities, goal, not so much because of an inherent flaw in the synergies, and efficiencies. This identification will also interventions, but because of the unpredictable behav- reflect how resources are often allocated in practice, ior of the system around them. Every intervention, for example, to schools or primary health care services, from the simplest to the most complex, has an effect rather than to specific interventions or disorders. on the overall system, and the overall system has an Chapter 10 of this volume (Petersen and others effect on every intervention (Savigny and Adam 2009). 2015) considers the evidence relating to interventions As a result of this, the current Disease Control Priorities that improve mental health at the population and com- series has shifted its focus from a strictly disorder- munity levels. This chapter outlines the main elements oriented intervention analysis (vertical approach) to a and features of a health care platform and its deliv- more horizontal approach focusing on health system ery channels, namely, informal health care, primary strengthening. health care, and specialized services. We consider This chapter seeks to identify cost-effective inter- evidence-based interventions that can be delivered ventions that can be appropriately packaged for one in general health care settings and mental health care or more specific mental, neurological, and substance settings, as well as broader health system–strengthening use (MNS) disorders, as well as for different levels or strategies for more effective and efficient delivery of platforms of the health or welfare system. A platform is services on this platform. the level of the health or welfare system at which inter- ventions can be appropriately, effectively, and efficiently delivered. A particular platform is defined on the basis ELEMENTS OF A MENTAL HEALTH CARE of where the intervention will be delivered (the setting) DELIVERY PLATFORM and who will deliver the intervention (service provider). There are essentially three major platforms for the Health care services as a delivery platform for improving provision of interventions: population, community, population mental health consist of three interlinked and health care. A specific delivery channel—such as a service delivery channels: school—can be the vehicle for the delivery of a partic- ular intervention on a specified platform (the commu- • Self-care and informal health care nity platform). Similarly, a primary health care center is • Primary health care the delivery channel for a specified platform (the health • Specialist health care. Corresponding author: Rahul Shidhaye, Centre for Chronic Conditions and Injuries, Public Health Foundation of India, rahul.shidhaye@phfi.org. 201 These three key delivery channels map well onto the health care services. Health promotion interventions commonly cited Service Organization Pyramid for an delivered at the population level can be important in Optimal Mix of Services for Mental Health supported by improving mental health literacy by helping people the World Health Organization (WHO) (figure 11.1) to recognize problems or illnesses, increasing their (WHO 2003a). At each subsequent level of the pyramid, knowledge about the causes of disorders and options the mental health needs of individuals become greater for treatment, and informing them about where to go and require more intensive professional assistance, usu- to get help (see chapter 10 in this volume, Petersen and ally resulting in higher costs of care. In certain settings others 2015). beset with conflict, natural disaster, or other emer- Informal health care comprises service providers gencies, a further channel for delivering much-needed who are not part of the formal health care system, such mental health care is humanitarian aid and emergency as traditional healers, village elders, faith-based organi- response. zations, peers, user and family associations, and lay people (WHO 2003a). Traditional and religious healers are of particular significance, as populations through- Self-Care and Informal Health Care out East Asia and Pacific, South Asia, Latin America The foundation of the health care delivery platform rests and the Caribbean, and Sub-Saharan Africa often use on self-care and emphasizes health worker–patient part- traditional medicine to meet their health needs (WHO nerships. Persons with MNS disorders and their family 2002). In many parts of the world, making contact with and friends play a central role in the management of men- such informal providers represents the initial pathway tal health problems. The role of individuals may range to care (Bekele and others 2009); these service provid- from collaborative decision-making concerning their ers are typically very accessible and more acceptable treatment, to actively adhering to prescribed medication, because they are integral members of the local com- to changing health-related behaviors, such as drug and munity. Given the widespread presence of traditional alcohol use, stress management, and identification of and religious healers and the shortage of human seizure triggers and avoiding them for seizure control. resources in mainstream biomedical services, it is Self-care is important for MNS disorders, but it imperative that primary health and other formal care is also important for the prevention and treatment services establish strong links with informal health care of physical health problems (WHO 2003a). Self-care providers, especially traditional healers (Patel 2011). It is most effective when it is supported by popula- is also critical to note that the evidence base regarding tionwide health promotion programs and formal the effectiveness of services provided by traditional and religious healers is limited. Nevertheless, it is essential to engage with them, as they provide acces- Figure 11.1 World Health Organization Service Organization Pyramid sible, acceptable, and affordable care, and efforts need for an Optimal Mix of Services for Mental Health to be made to ensure that their practices do not harm the patients. Low High Peers are another key human resource at this level of health care. Peer-led education and behavioral inter- Long-stay ventions have been effective with target populations facilities and specialist services and health issues in low- and middle-income countries Psychiatric Community (LMICs) (Manandhar and others 2004; Medley and services in mental health general services others 2009; Tripathy and others 2010). Peers are more hospitals numerous, may be perceived as more approachable, and Costs Frequency of need Primary care services for may be able to identify with other community members, Se mental health lf-c as they share similar characteristics, experiences, and are Informal community care health conditions with members of the target population Informal services (Simoni and others 2011). Mental health self-help groups form another key Self-care component of informal community care. Mental health self-help groups may be defined as “any mutual support Quantity of services needed oriented initiative directed by people with [MNS disor- High Low ders] or their family members” (Brown and others 2008, Source: Reprinted from Mental Health Policy and Service Guidance Package, World Health Organization 105). Participation in mental health self-help groups has (WHO), “Organization of Services for Mental health,” page 34, WHO 2003a. Reprinted with permission. a positive impact on the clinical and social outcomes 202 Mental, Neurological, and Substance Use Disorders of patients with MNS disorders (Pistrang, Barker, and acute exacerbations of physical health conditions Humphreys 2008). Some of these self-help groups are (WHO 2003a). primarily concerned with the provision of peer support, The mental health services provided in first-level while others may devote their efforts toward changing hospitals also enable 24-hour access to services for any public policies and, more broadly, changing public physical health problems that might arise during the attitudes. Still others may focus on self-empowerment, course of inpatient stays. Ideally, first-level hospitals will including monitoring and critiquing the mental health have wards dedicated to the treatment of MNS disor- services they are receiving (Cohen and others 2012). ders; these wards will have floor plans that support good Social support also plays an important role in self- observation and care, minimizing the risk of neglect and management of epilepsy (Jayalakshmi and others 2014; suicide. To minimize the risk of human rights violations, Walker and others 2014). However, informal commu- facilities should adhere to clear policies and guidelines nity care should not be viewed as a substitute for pub- that support the treatment and management of MNS licly funded, evidence-based mental health care. disorders within a framework that promotes human Stigmatization of and discrimination against people dignity and uses evidence-based clinical practice. with MNS disorders is common in all sections of soci- In addition, specialist mental health services are ety, from community to schools, workplace, and even needed in the community for severe cases that cannot health care settings. Stigma and discrimination pres- be managed by generalists. Examples include assertive ent formidable barriers to social inclusion for affected community treatment teams and community outreach people and their families, and to access to appropriate teams, which provide support to service users to enable health care (Shidhaye and Kermode 2013). This is par- them to continue to function in the community without ticularly important in the area of self-care and infor- requiring admission, and close liaison with general pri- mal care services, which are relatively less regulated mary care services and other social and criminal justice and less subject to quality review or policy oversight. services (WHO 2003a). Interventions at the community level to address nega- tive attitudes toward people with MNS disorders and Extended-Stay Facilities and Specialist improve health care utilization are covered in chapter 10 Psychiatric Services in this volume (Petersen and others 2015). A small minority of people with MNS disorders requires specialist care (WHO 2003a). For example, people with treatment-resistant or complex presentations may need Primary Health Care to be referred to specialized centers for further testing Delivery of mental health services through primary health and treatment. In LMICs with meager resources, the care is a fundamental component of a mental health demand of the population and the emphasis of the public care delivery platform, since it serves as the first level health system is to treat persons with severe MNS disor- of care within the formal health care system. The strong ders. These aspects of care provision along with services emphasis on primary health care is due to the fact that for vulnerable populations—such as individuals living the services provided at this level of the health system in abject poverty; women, especially in childbearing age; are generally accessible, affordable, and acceptable for children facing abuse; and elderly persons—should not individuals, families, and communities (WHO 2003a). be overlooked when designing programs. Where the provision of mental health care is integrated Because of their severe mental disorders or intel- into these services, access is improved, MNS disorders are lectual disabilities and lack of family support, many more likely to be identified and treated, and comorbid of these individuals may occasionally require ongo- physical and mental health problems can be managed ing care in community-based residential facilities. more seamlessly. Unfortunately, very scarce resources are allocated to these services. The vulnerable populations require par- ticular attention, from a mental health care perspective Specialist Health Care and a financial risk protection perspective. The final Psychiatric Services in First-Level Hospitals and part of this volume addresses the issue of financial risk Community Mental Health Services protection at length. Forensic psychiatry is another People with severe MNS disorders may require hospi- type of specialist service in this category. The need talization at some point. First-level hospitals provide for referral to specialist and extended-stay services an accessible and acceptable location for 24-hour is reduced when first-level hospitals are staffed with medical care for people with acute worsening of dis- highly specialized health workers, such as psychiatrists orders, in the same way that these facilities manage and psychologists. Health Care Platform Interventions 203 Emergency Mental Health Care EVIDENCE-BASED INTERVENTIONS FOR The traumas, personal losses, and other consequences HEALTH CARE DELIVERY PLATFORMS of armed conflict and disasters place affected popu- A strong evidence base supports integrated services lations at an increased risk of mental and behavioral across the different delivery channels of the health care problems; these consequences can overwhelm the local platform. This evidence has been synthesized in sev- capacity to respond, particularly if the existing infra- eral publications, including the mhGAP Intervention structure or health system is already weak. Moreover, Guide (WHO 2010b); a series of papers on packages the local health care system may have been rendered of care for MNS disorders in LMICs, published in dysfunctional as a result of the emergency situation, PLoS Medicine (Patel and Thornicroft 2009); and a placing further limits on access to key resources, such report on mental health in primary health care (WHO as mental health professionals or essential psychotro- and WONCA 2008). Earlier disagreement and con- pic medicines. There is a heightened need to iden- troversy over emergency mental health care has given tify and allocate resources to provide mental health way to emerging consensus on key social and mental and psychosocial support in these humanitarian set- health intervention strategies and principles, as exem- tings, for those with mental or behavioral problems plified by the Inter-Agency Standing Committee’s induced by emergencies and those with preexisting Guidelines on Mental Health and Psychosocial Support illness. International humanitarian aid and emergency in Emergency Settings (IASC 2007); the inclusion of response at the national level can be a channel for a mental and social aspects of health standard in the rapidly enabling or supporting the availability of and handbook on minimal standards in disaster response access to basic or specialist care. In many countries, (Sphere 2011); and the report on sustainable mental such emergencies have provided opportunities for health care after emergencies, Building Back Better systemic change or service reform in public mental (WHO 2013a). health (WHO 2013a). Emergency response or relief For each of the delivery channels, interventions may efforts are essentially concerned with setting up, orga- be categorized as follows: nizing, and rebuilding services for local populations; the central principles and standard practice of care, including what evidence-based interventions should • Promotion and primary prevention be prioritized, remain unchanged. • Identification and case detection • Treatment, care, and rehabilitation. Relationships among Different Delivery Channels Table 11.1 summarizes the evidence base for No single service delivery channel can meet all mental interventions by various delivery channels. The inter- health needs. For example, on the one hand, primary ventions are intended as examples rather than as mental health care must be complemented by special- recommendations. ist care services that primary health workers can use for referrals, support, and supervision; on the other hand, primary mental health care needs to promote SYSTEM-STRENGTHENING STRATEGIES FOR and support self-care and informal community care INTEGRATED HEALTH CARE DELIVERY that encourages the involvement of people in their own recovery. Support of self-care and management The availability of evidence-based interventions does not can be provided via routine primary care visits or via ensure their translation into practice. In this section, we group sessions led by health or lay workers in health address the question of how to integrate evidence-based care settings or community venues. Another increas- mental health care interventions into primary care and ingly accessible option for the effective support of self-care delivery channels and how to link this integra- self-care and management is telephone- or Internet- tion to specialist care. based programs. In short, the potential of the health A comprehensive and multifaceted approach that care system as a delivery platform for enhanced men- contains the following elements is essential for the tal health and well-being can only be fully realized if successful integration of mental health into health care genuine continuity and collaboration of care occur systems: across the three service delivery channels; continuity and collaboration, in turn, rely on an appropriate • A whole-of-government approach involves the pro- flow of support, supervision, information-sharing, motion, pursuit, and protection of health through and education. concerted action by many sectors of government. 204 Mental, Neurological, and Substance Use Disorders Table 11.1 Examples of Evidence-Based Interventions Relating to the Mental Health Care Delivery Platform, by Various Delivery Channels Promotion and primary Identification and case Delivery channel prevention detection Treatment, care, and rehabilitation Self-care and • Adoption of a healthy • Self-detection of • Web-based psychological therapy for depression informal health care lifestyle, including diet and depression and anxiety and anxiety disorders physical activity disorders • Self-managed treatment of migraine • Self-monitoring of high- • Self-identification and management of seizure risk behaviors, such as triggers substance abuse • Improved adherence to anti-epileptic treatment by intensive reminders and implementation intention interventions Primary health care • Parent skills training • Screening for • Management—pharmacological and for internalizing and developmental delays in psychosocial interventions—of depression, externalizing problems in children anxiety, psychosis, alcohol use disorders, child and parental mental • Screening and brief epilepsy, dementia, and drug use based on health interventions for alcohol mhGAP Intervention Guidelines use disorders by trained • Cognitive behavioral therapy–based interventions primary health care staff for anxiety disorders in children • Community-based case- • Cognitive behavioral therapy–based interventions finding of psychosis and for depression and anxiety disorders in adults severe depression and mothers in the perinatal period • Diagnosis of depression, • Management of alcohol withdrawal in anxiety disorders, maternal conjunction with motivational interviewing and depression, alcohol use motivation enhancement involving family and disorders, dementia, friends headaches, and epilepsy • Interventions for caregivers of patients with psychosis and dementia Specialist health • Diagnosis of complex • Electroconvulsive therapy for severe refractory care childhood mental disorders depression • Diagnosis of severe • Surgical interventions for refractory epilepsy psychosis and depression • Pharmacological management of dementia • Diagnosis of secondary (cholinesterase inhibitors and memantine) causes of headache • Methadone maintenance therapy for opioid dependence, buprenorphine as opioid substitution therapy • Management of refractory psychosis using clozapine • Management of severe alcohol withdrawal • Management of severe maternal depression using antidepressants • Stimulant medication for severe cases of attention-deficit hyperactivity disorder • Cognitive behavioral therapy–based interventions and anger control training for adolescents with disruptive behavioral disorders Note: The list of evidence-based interventions in the table is for illustration. mhGAP = Mental Health Gap Action Programme (WHO 2010b). Health Care Platform Interventions 205 These include ministries of planning and develop- boost efforts to deliver mental health services at the ment, finance, law and justice, labor, education, and primary care level (WHO and WONCA 2008). social welfare. The health system cannot tackle the health, social, and economic determinants and con- How to operationalize the public health, whole-of- sequences of MNS disorders alone. government, and systems approaches to integrate service • A public health approach stresses the establishment of delivery for MNS disorders is a major challenge. In South partnerships between patients and service providers, Africa, some important steps have been taken toward as well as equitable access for the whole population intersectoral collaboration, particularly at the national (Lund and others 2012). This approach requires the level, such as a national forum on forensic psychiatry integration of care at the patient level. Services should convened by the Department of Health, with the South be person centered and coordinated across diseases African Police Service (SAPS), the Department of Justice, and settings. Collaborative, coordinated, and continu- and the Department of Correctional Services. The ing care, within a framework of evidence-based inter- Departments of Education and Correctional Services ventions, provides the foundation of the public health have developed policies regarding mental health, and approach. This means providing good quality, acces- SAPS has developed a standing order that sets out roles sible services to those in need, as well as preventing and responsibilities for police in relation to mental the onset of disease and promoting mental health and health. At the provincial level, there are formal collabo- well-being over the entire life course (WHO 2010a). rations between the government department responsible Priority setting and provision of interventions based for mental health and other departments and agencies in on the needs of the population under consideration most provinces across a range of sectors. Some provinces are also an integral part of the public health approach, have also established intersectoral forums for mental which is also central to the work undertaken by the health, and intersectoral collaboration is a standing item Disease Control Priorities Network. on the agenda of the quarterly meetings of the provincial mental health coordinators. However, at the district level, Table 11.2 summarizes the key features of a public such intersectoral collaboration is not common. A policy mental health approach. brief prepared by the Mental Health and Poverty Project provides specific recommendations for shared respon- • A systems approach to integrated service planning sibilities in policy and program development among and development encompasses the critical ingredients sectors, such as education, social development, housing, of a health system—good governance, appropriate justice and constitutional development, correctional ser- resourcing, timely information, and the actual delivery vices, labor, local government, public works, and mental of health services or technologies—that need to be in health (MHaPP 2008). place for desired health outcomes or program goals Many evidence-based interventions fail to translate to be realized. Effective governance, strong leadership, into practice because key decision makers, especially and cogent policy making merit particular mention, in LMICs, are merely seen as targets for dissemination since they provide the framework for appropriate of study results by academicians and researchers. To action and subsequent service development. Indeed, address this challenge, it is imperative to understand a well-articulated mental health policy, along with a that research should be concerned with the users of clear mental health implementation plan and budget, the research and not purely the production of knowl- can be a strong driver for change and can appreciably edge. The users may include managers and teams using Table 11.2 Key Characteristics of a Public Health Approach to MNS Disorder Prevention and Management Prevention essentials Management essentials Promotion of healthy behaviors Person-centered care and support Prevention of exposure to adverse events and risks Family and community support Early detection Coordinated, holistic care Intersectoral collaboration Continuity of care and proactive follow-up Life course approach Source: WHO and Calouste Gulbenkian Foundation 2014. Note: MNS = mental, neurological, and substance use. 206 Mental, Neurological, and Substance Use Disorders research findings, executive decision makers seeking There is provision for regular and planned monitoring advice for specific decisions, policy makers who need to of patients and systematic caseload reviews and consul- be informed about particular programs, practitioners tation with mental health specialists regarding patients who need to be convinced to use interventions that are who do not show clinical improvement (WHO and based on evidence, people who are influenced to change Calouste Gulbenkian Foundation 2014). their behavior to have a healthier life, or communities Collaborative care is the best-evaluated model for that are conducting the research and taking action treating common mental disorders in primary care. through the research to improve their conditions. It A recent Cochrane Collaboration review of 79 random- is critical to involve these actors in the identification, ized controlled trials concluded that collaborative care for design, and conduct phases of research and program depression is consistently more effective than usual care; implementation (Peters and others 2013). it has also been shown to be effective in a range of MNS Within the three broad approaches, specific strategies disorders—anxiety disorders and post-traumatic stress can be identified for integrated health care delivery. disorder—and for improving general health outcomes. The evidence base for collaborative care is mostly from high-income countries (HICs), although evidence from Strategy 1: Improving the Organization and Delivery of LMICs is growing (Archer and others 2012). It might Services through Collaborative Stepped Care be very difficult to replicate these case studies directly Collaborative care is an evidence-based approach to in low-income settings, but it is possible to extract the improve the management of MNS disorders at the pri- lessons from these experiences and contextualize them mary care level. The overall aim of collaborative care is to for a particular setting. There is absolutely no one-size- enhance the quality of care and quality of life, consumer fits-all strategy for the heterogeneous settings across satisfaction, and system efficiency for patients with com- and within the countries. It is critical to test rigorously plex, long-term problems (Kodner and Spreeuwenberg and generate evidence around the contextualization of 2002). Collaborative care has been used successfully for these strategies in low-resource settings. The Balanced the management of common mental disorders, such as Care Model provides guidelines for the inclusion of pro- depression, as well as for comorbidities cutting across gram components that are appropriate for the available multiple services, providers, and settings (Katon and resources (Thornicroft and Tansella 2013). others 2010). Collaborative care is closely related to a Mental health programs can be designed on the basis stepped care approach; some programs describe them- of these guiding principles, drawing on the following selves as collaborative stepped care, in that they incorpo- case studies. rate aspects of each approach within their interventions (Patel and others 2010). In the stepped care approach, • The MANAS (MANashanti Sudhar Shodh, or project patients typically start treatment with low-intensity, to promote mental health) study in Goa, India, is the low-cost interventions. Treatment results are monitored largest mental health care trial to date in that country. systematically, and patients move to a higher-intensity The study showed that a lay counselor–led collabo- treatment only if necessary. Programs seek to maxi- rative stepped care intervention for depression and mize efficiency by deploying available human resources anxiety disorders in primary health care settings led according to need, reserving the most specialized and to substantial reductions in the prevalence of these intensive resources for those with the most complex or disorders, suicidal behaviors, and days of work lost, severe problems. compared with usual care. The trial also evaluated The essential element of collaborative care is a mul- the economic impact of the intervention and found tidisciplinary team approach that seeks to integrate that the overall health system costs were lower in primary care professionals and specialists. Collaborative the intervention arm, despite the intervention costs, care rests primarily on the presence of a case manager because patients recovered sooner and had lower with enhanced responsibilities for integration of care overall health care costs (Patel and others 2010). across comorbid conditions. It starts with systematic • The Home Care Program for elderly people affected identification of those in need, followed by close involve- by dementia, led by the Dementia Society of Goa, ment of patients in joint decision-making regarding evaluated a community-based collaborative care their care. It continues with the design of a holistic care model led by lay counselors. The model showed plan that includes medication management and psy- benefits in reducing caregiver burden and improving chological interventions and, where appropriate, social caregiver mental health (Dias and others 2008). care, with a streamlined referral pathway that allows • In Chile, a multicomponent intervention lasting patients to move easily from one service to another. three months and comprising nine weekly sessions Health Care Platform Interventions 207 of psychoeducational groups, structured and sys- from a specialist mental health team, which makes tematic follow-up, and pharmacotherapy for women regular visits to family health centers. Joint consulta- with severe depression, and led by nonmedical tions are undertaken among mental health specialists, health workers, demonstrated that at the six-month primary care practitioners, and patients. This model follow-up, 70 percent of the stepped care group had ensures good-quality mental health care, and it serves recovered, compared with 30 percent in the usual- as a training and supervision tool whereby primary care group (Araya and others 2003). The program is care practitioners gain skills that enable greater com- being rolled out across Chile. A similar program was petence and autonomy in managing mental disorders subsequently tested among low-income mothers in (WHO and WONCA 2008). postnatal primary care clinics in Santiago, Chile. The • A similar model is being practiced as part program demonstrated significant improvement in of the District Mental Health Programme in the intervention group (Rojas and others 2007). Thiruvananthapuram district, Kerala, India. Trained • In Ibadan, Nigeria, a pilot study evaluated the use- medical officers diagnose and treat mental disor- fulness of a stepped care intervention for depression. ders as part of their general primary care func- The intervention was delivered by non-physician tions. A multidisciplinary district mental health primary health workers, with support and super- team provides outreach clinical services, including vision by physicians and psychiatrists, as needed, direct management of complex cases and in-service using mobile phones. The intervention was based on training and support of the trained medical officers WHO’s mhGAP guidelines, adapted for the Nigerian and other workers in the primary care centers. The health system. Recovery at follow-up, defined as no primary care centers have incrementally assumed longer meeting the Diagnostic and Statistical Manual responsibility for independently operating mental of Mental Disorders: DSM-IV-TR, 4th edition (APA health clinics with minimal support from the mental 2000), major depression criteria at six months, health team (WHO and WONCA 2008). was achieved by 73.0 percent of the participants • In the Moorreesburg district of Western Cape prov- in the intervention group and 51.6 percent in the ince, South Africa, the role of primary care practi- usual-care group, representing a risk difference of tioners is filled by general primary care nurses, who 21.4 percent. A fully powered study is being imple- provide basic mental health services in the primary mented to determine the effectiveness and cost- health clinic. They are supported by specialist mental effectiveness of the package (WHO and Calouste health nurses and a psychiatrist, who visits the clinic Gulbenkian Foundation 2014). intermittently to manage complex cases and provide • The Headache Management Trial assessed the effect supervision (WHO and WONCA 2008). of a coordinated headache management program • The European Headache Federation and Lifting the in general clinical practice. Patients in the interven- Burden: the Global Campaign against Headache tion arm received a headache management program (Steiner and others 2011) has proposed a collabo- consisting of a class specifically designed to inform rative care model for the management of headache them about headache types, triggers, and treatment disorders. In this model, 90 percent of people con- options; diagnosis and treatment by a professional sulting for migraine and tension-type headaches can specially trained in headache care; and proactive be diagnosed and managed by staff at the primary follow-up by a case manager. This trial demonstrated care level. In the case of the remaining 10 percent that a systematic approach to headache care is prac- of the patients, common primary and secondary tical and achievable in a general clinical setting and headache disorders can be recognized but not nec- effectively reduced headache disability in a wide essarily managed; these can be referred to the next range of patients (Matchar and others 2008). level, where physicians can provide more advanced care. Finally, specialists can provide advanced care to These case studies primarily focused on evidence approximately 1 percent of patients first seen at the generation and were conducted in controlled settings. first-level and second-level facilities, and can focus There are also several case studies from LMICs. on the diagnosis and management of the underlying causes of all secondary headache disorders. There is • In the city of Sobral, Brazil, primary care practition- a demonstrational intervention project based on this ers conducted physical and mental health assessments model in Yekaterinburg, Sverdlovsk Oblast, Russian for all patients as part of integrated primary care Federation (Lebedeva and others 2013). Headache for mental health. Primary care practitioners treat services in China have been designed on this model patients if they are able, or request an assessment (Yu and others 2014). 208 Mental, Neurological, and Substance Use Disorders The collaborative stepped care approach relies heav- care for mental health is usually most effective where a ily on the introduction of additional human resources, mental health coordinator or case manager is responsible identification of core competencies, adequate training for overseeing integration (WHO and WONCA 2008). to ensure that these core competencies are fulfilled, These case managers can play a crucial role in screening; and specialist support to maintain these competencies. engaging; educating patients and family members; main- The next section describes this critical component of taining close follow-up; tracking adherence and clinical mental health system strengthening in more detail. outcomes; and delivering targeted, evidence-based, psy- chological interventions, such as motivational inter- viewing, behavioral activation, problem solving, or Strategy 2: Strengthening Human Resources for interpersonal therapy (Patel and others 2013). The case Mental Health through Task-Sharing managers can serve as the link between the primary care One of the main reasons for the substantial treatment and self-care platforms, and can work under the close gap for MNS disorders is the lack of a skilled work- supervision of the medical officers. The evidence base force. In HICs, the number of mental health workers for psychological interventions delivered using a task- is often inadequate; in LMICs, the situation is dramat- sharing approach is set out in box 11.1. ically worse, with an estimated shortage of 1.18 million A recent multi-site, qualitative study as part of the workers (Kakuma and others 2011). The collaborative PRogramme for Improving Mental health carE (PRIME) stepped care approach can be implemented only if investigated the acceptability and feasibility of task- skilled human resources are available at the different sharing mental health care in five LMICs. The study levels of service delivery. examined the perceptions of primary care service provid- ers (physicians, nurses, and community health workers), Task-Sharing Approach community members, and service users (Mendenhall Task-sharing is a human resource innovation in which and others 2014). Task-sharing mental health services is the skills to deliver specific mental health care tasks feasible as long as the following key conditions are met: are transferred to appropriately trained and supervised general health workers. This process helps in improving • Increased numbers of human resources and better access to evidence-based mental health care and leads to access to medications more efficient use of the limited resources. This approach • Ongoing structured supportive supervision at the has been evaluated for mental health service delivery, and community and primary care levels its efficacy has been established using rigorous evalua- • Adequate training and compensation for health tion methodologies (Araya and others 2003; Patel and workers involved in task-sharing. others 2010; Rahman and others 2008). Task-sharing is implemented through a collaborative care framework Competency-Based Education with four key human resources: the community health Primary care workers function best when their tasks worker or case manager; the person with a mental health related to mental health service delivery are limited and problem and family members; the primary or general achievable. The most common reasons for failure to inte- health care physician; and the mental health professional grate mental health care into primary care programs are (Bower and Gilbody 2005). The overall shortage of the lack of adequate assessment and the overly ambitious human resources can be addressed by introducing newly target-setting without the necessary customization of the skilled nonspecialist health workers at the community detailed activities, and a full and explicit agreement on level; reorienting medical officers and paramedical staff the targets and activities needed to achieve them (Patel to integrate mental health interventions; and redefining and others 2013). A shift away from knowledge-based the role of specialists from service providers to leaders, education to competency-based education is needed. trainers, and supervisors of mental health programs. This approach mainly focuses on the skills of providers, The task-sharing approach is at the heart of estab- with the ultimate goal of improving patient outcomes. lishing the collaborative stepped care model of care; the Competency is defined as an attribute of an individual most crucial element in this approach is the availability human resource and the ability of that worker to deliver of a case manager. The results of the MANAS trial clearly an intervention to a desired performance standard based indicate the effectiveness of a lay health counselor or case on the acquired knowledge and skills. manager leading the collaborative stepped care interven- The Institute of Medicine’s (IOM) Forum on tion for common mental disorders in public primary Neuroscience and Nervous System Disorders convened a health care facilities in India (Patel and others 2010). workshop to discuss and identify core competencies that Several global case studies have found that primary specialized and nonspecialized primary care providers Health Care Platform Interventions 209 Box 11.1 Clinical and Functional Outcomes of Psychological Interventions Delivered Using a Task-Sharing Approach • Recovery of adults suffering from depression or • Improvement in the mental well-being, burden, anxiety, or both, at 7–12 months following the and distress of caregivers of people with dementia intervention • Decrease in the amount of alcohol consumed by • Reduction in symptoms for mothers with perina- people with alcohol-use disorders tal depression symptoms • Reduction in functional impairment of children • Reduction in the prevalence and the symptoms affected by post-traumatic stress disorder at six of adults with post-traumatic stress disorder over and 12 months following the intervention. six months • Improvement in symptoms of people with Sources: Clarke, King, and Prost 2013; van Ginneken and others 2013. dementia might need to help ensure the effective delivery of ser- mental health specialists, increases the skills of primary vices for depression, psychosis, epilepsy, and alcohol use care workers and builds mental health networks (WHO disorders in Sub-Saharan Africa (IOM 2013). Table 11.3 and WONCA 2008). lists the steps to strengthen human resource compe- tencies for MNS disorders; the core competencies for Specialist Transitioning all service providers across MNS disorders are listed in Specialists, especially in LMICs, are usually engaged in table 11.4. In addition to the common competencies for service delivery. It is imperative to make a transition from all service providers, the IOM framework also focuses on providing clinical services to training and supervising a diverse range of cadre-specific competencies. the primary health care staff and providing direct clin- Pre-service and in-service training of primary care ical interventions judiciously and sparingly. In separate workers on mental health issues is an essential prereq- projects focusing on integrated primary care for mental uisite for the integration of mental health into primary health in the city of Sobral, Brazil, and the Sembabule dis- care platforms. The training, to the extent possible, trict of Uganda, specialists together with medical officers should happen in primary care or community mental in primary care visited primary care settings and assessed health care facilities, to ensure that practical experience patients. Over time, psychiatrists started taking less active is gained and that ongoing training and support are roles, while general practitioners assumed added respon- facilitated (WHO and WONCA 2008). The effects of sibilities, under the supervision of the psychiatrists. training are nearly always short lived if health workers Specialists can interact with primary care staff via referral do not practice newly learned skills and receive ongoing and back-referral (WHO and WONCA 2008). specialist supervision. A trial from Kenya did not find any impact of the training program of medical officers Planning and Consultation on improvement in diagnostic rates of mental disor- Involving primary health care staff in the overall program ders (Jenkins and others 2013). A quasi-experimental planning and rollout process enhances ownership and study from Brazil had similar findings and noted that commitment to achieve the planned outcomes within wider changes in the system of care may be required agreed timelines (Patel and others 2013). Consultations to augment training and encourage reliable changes in with general practitioners have been demonstrated to be clinical practice (Goncalves and others 2013). Ongoing one of the key factors in the success of the new mental support and supervision from mental health specialists health services in Australia (WHO and WONCA 2008). are essential. Case studies from Australia, Brazil, and Decisions need to be made after careful consideration South Africa have demonstrated that a collaborative of local circumstances; this requires consultation with stepped care approach, in which joint consultations and policy makers as well as users of mental health services interventions occur between primary care workers and and their families and the primary care staff. 210 Mental, Neurological, and Substance Use Disorders Table 11.3 Steps to Strengthen Human Resource Competencies for MNS Disorders Step 1: Understand the tasks necessary for delivering evidence-based interventions. Step 2: Define the candidate core competencies needed to perform those tasks to an expected standard, acknowledging that there might be limits to what a particular human resource category may be able to do, or is permitted to do in a particular context. Step 3: Define how individual health care workers can acquire and maintain these competencies and how to evaluate them. Source: IOM 2013. Note: MNS = mental, neurological, and substance use. Table 11.4 Core Competencies for All Service Providers across MNS Disorders Competency Screening and identification • Demonstrate awareness of common signs and symptoms of MNS disorders • Recognize the potential for risk to self and others • Demonstrate basic knowledge of causes • Provide the patient and community with awareness and education • Demonstrate cultural competence • Demonstrate knowledge of other MNS disorders Formal diagnosis and referral • Demonstrate knowledge of when to refer to the next level of care or other providers • Demonstrate knowledge of providers for specialized care within the community Treatment and care • Provide support for patients and families while in treatment and care • Identify and assist patients and families in overcoming barriers to successful treatment and recovery, for example, adherence, stigma, finances, accessibility, and access to social support • Demonstrate ability to monitor mental status • Demonstrate knowledge of how to offer emergency first aid • Initiate and participate in community-based treatment, care, and prevention programs • Demonstrate knowledge of treatment and care resources in the community • Promote mental health literacy, for example, to minimize the impact of stigma and discrimination • Communicate to the public about MNS disorders • Monitor for adherence to regimens and side effects of medication • Practice good therapeutic patient interactions, for example, communication, relationship, and attitude • Provide links between patients and community resources • Identify available resources to support patients, for example, rehabilitation and medication supplies • Promote activities to raise awareness and improve the uptake of interventions and the use of services • Protect patients and identify vulnerabilities, for example, human rights • Demonstrate respect, compassion, and responsiveness to patient needs • Demonstrate knowledge and skills to use information technology to improve treatment and care. Source: IOM 2013. Note: MNS = mental, neurological, and substance use. Health Care Platform Interventions 211 Psychotropic Medications suggests the benefits of the integration of maternal It is important to ensure that primary care staff members mental health into maternal and child health (MCH) have the appropriate permission to prescribe psychotro- programs. Examples of community-based trials with pic medications, and they must be adequately trained to a maternal mental health component integrated into perform this task. In many countries, nurses and even an MCH program, and a case study demonstrat- general physicians are not permitted to prescribe psy- ing that the screening and management of maternal chotropic medications. If access to psychotropic medica- mental disorders can be integrated successfully into tions is to be improved, then initiatives to allow primary an existing health system at a facility level, build a care nurses to prescribe psychotropic medications need strong case for the integration of mental health care to be promoted and undertaken, provided appropriate into MCH programs (Rahman and others 2013). The training and supervision is conducted. In Belize, psychi- Thinking Healthy Programme in Pakistan is a simple atric nurse practitioners have been given additional pre- and culturally appropriate intervention for integrating scription rights. In Uganda, general primary care nurses depression care into an MCH program. The interven- are permitted to prescribe psychotropic medication to tion is child centered, ensuring buy-in from the fam- patients who require continued medication on the rec- ilies and avoiding stigmatization. It is woven into the ommendation of a mental health professional (WHO routine work of the community health workers, so it and WONCA 2008). is not perceived as an additional burden. The Thinking Healthy Programme has been further adapted so that it can be used universally for all women rather than only Strategy 3: Integrating Mental Health into Existing depressed women (Rahman and others 2013). Health Programs The Perinatal Mental Health Project in the Western MNS disorders frequently occur throughout the course Cape Province in South Africa developed a stepped of many noncommunicable diseases and infectious care intervention for maternal mental health that is diseases, such as HIV/AIDS and tuberculosis, increas- integrated into antenatal care in three primary care ing morbidity and mortality (Prince and others 2007). midwife obstetric units (Honikman and others 2012). People with comorbid disorders risk poor outcomes Midwives are trained to screen women routinely dur- for both disorders. To achieve the desired outcomes ing their antenatal visits for maternal mood and for priority programs in the health sector, it is cru- anxiety disorders. Women who screen positive for cial to manage MNS disorders, pursue synergies in anxiety or depression are referred to onsite counselors the health system, and deliver interventions through who also act as case managers. Women are referred to integrated approaches to care. Expansion and integra- an onsite psychiatrist when specialist intervention is tion of mental health services in primary health care indicated. The Perinatal Mental Health Project works can be achieved by using existing service delivery for directly with facility managers and health workers maternal and child health, noncommunicable diseases, through collaborative partnerships, focusing on prob- and HIV/AIDS and tuberculosis (Collins and others lem solving and capacity development in the primary 2013). Patients with severe MNS disorders often do health care system. Over a three-year period, 90 percent not receive appropriate care for their general health of all women attending antenatal care in the mater- conditions because of the negative attitudes of service nity clinic were offered mental health screening, with providers, resulting in reductions of 10–25 years in 95 percent uptake. Of those screened, 32 percent qual- life expectancy compared with the general population. ified for referral; of these, 47 percent received coun- Integration of MNS services within other health care seling through the program. This case study clearly platforms is essential. demonstrates that onsite, integrated mental health services can increase access for women who have scarce Maternal and Child Health Programs resources and competing health, family, and economic Maternal depression is the second leading cause of disease priorities (Honikman and others 2012). burden in women worldwide, following infections and Parenting skills training aims to enhance and support parasitic diseases (Rahman and others 2013). Systematic the parental role through education and skills enhance- reviews from HICs provide evidence of the effectiveness ment, thereby improving emotional and behavioral of psychological therapies—including cognitive behav- outcomes for children. Primary health care workers ioral therapy (CBT) and interpersonal therapy that can play a significant role in this training. The use of can be delivered in individual or group format—and scarce professional resources to train parents is a cost- pharmacotherapy in the treatment of maternal depres- effective use of resources. Several systematic reviews have sion (Rahman and others 2013). Promising evidence shown parent skills training to be effective for reducing 212 Mental, Neurological, and Substance Use Disorders internalizing and externalizing problems in children severe depression (Araya and others 2012). In Myanmar (Furlong and others 2012; Kaminski and others 2008), and several other LMICs, epilepsy has been included as as well as reducing the risk of unintentional childhood part of the process of local adaptation and implemen- injuries (Kendrick and others 2013) and improving tation of WHO’s package of essential noncommunica- the mental health of parents (Barlow and others 2014). ble disease interventions in primary care (WHO and Individual and group parent training have been benefi- Calouste Gulbenkian Foundation 2014). cial. Four components of parenting skills training have Care for patients with dementia can be well inte- been found to be most effective: grated with health care for noncommunicable dis- eases. Patients with dementia need to be assessed for • Increasing positive parent-child interactions behavioral and psychosocial symptoms, in addition to • Teaching parents how to communicate emotionally a careful physical assessment to monitor hearing and with their children visual impairments, pain, constipation, urinary tract • Teaching parents the use of time-out as a means of infections, and bed sores that may explain some exac- discipline erbation of psychological symptoms. Monitoring and • Supporting parents to respond in a consistent man- effective treatment of vascular risk factors and diseases, ner to their children’s behavior (Kaminski and others including high blood pressure, hypercholesterolemia, 2008). smoking, obesity, and diabetes, to improve secondary prevention of cerebrovascular events, are an integral Noncommunicable Disease Programs component of care. A well-conducted clinical trial of Existing service delivery platforms for noncommuni- cognitive stimulation (reality orientation, games, and cable diseases are also promising entry points for the discussions based on information processing rather integration of mental health into primary care. The col- than knowledge) conducted in the United Kingdom as laborative care models discussed demonstrate a strong a group intervention and a small pilot trial from Brazil evidence base for integration in primary care settings. suggest that cognitive benefits from this intervention In North America, TEAMcare USA and TEAMcare are similar to the benefits from pharmacological man- Canada provide team-based primary care for diabetes, agement of dementia using cholinesterase inhibitors coronary heart disease, and depression. TEAMcare trains (Prince and others 2009). Cognitive rehabilitation, an primary care staff to work in collaborative teams that individualized therapy designed to enhance residual deliver care in a clinic and by phone. Each service user is cognitive skills and cope with deficits, showed promise assigned a TEAMcare care manager, usually a medically in uncontrolled case series undertaken in HICs. A large supervised nurse, who serves as the conduit for the con- body of literature attests to the benefits of caregiver sultation team, the primary care team, and the service user. interventions in dementia. These include psychoedu- The program takes a treat-to-target approach, modifying cational interventions, often caregiver training; psycho- treatment as needed to ensure improvement in symptoms. logical therapies such as CBT and counseling; caregiver The program teaches self-care skills to service users to support; and respite care (Chapter 5 in this volume, control illnesses and encourages behaviors that enhance Thakur and others 2015). Many interventions combine the quality of life. About 1,400 people have received several of these elements. Interventions targeting the TEAMcare, with a trial showing improvements in medical caregiver may have small, but significant, beneficial disease control and depression symptoms (Katon and effects on the behavior of the person with dementia. others 2012). In the United Kingdom, 3 Dimensions of Care for Diabetes uses a team consisting of a psychiatrist HIV/AIDS and Tuberculosis Programs and a social worker from a nongovernmental organization WHO’s Integrated Management of Adult and embedded in the diabetes care team to integrate medical, Adolescent Illness (IMAI) is a broadly disseminated psychological, and social care for people with diabetes health care strategy that addresses the overall health of and mental health problems, and social problems, such patients with HIV/AIDS and co-occurring tuberculosis; as housing and debt (Parsonage, Fossey, and Tutty 2012). clear opportunities exist for the integration of mental The National Depression Detection and Treatment health in this program. IMAI promotes the inclusion Program in Chile integrated depression care with more of mental health in the overall care model for HIV/ traditional primary care programs for the management AIDS, as the mental health needs of many persons of hypertension and diabetes within a network of 520 living with HIV/AIDS can be largely addressed with primary care clinics. The program follows a collaborative little duplication or waste, while improving program stepped care approach and is led by psychologists, with outcomes, such as antiretroviral drug adherence (WHO additional support from physicians and specialists for 2013b). Interventions for substance use disorders can be Health Care Platform Interventions 213 integrated with HIV/AIDS interventions. This delivery of care dimension. There is a significant gap between channel can be used to identify individuals who use what is known about effective treatment and what is injectable drugs, as well as those with dependence on actually provided to and experienced by consumers opioids, cannabis, and cocaine. The evidence base sup- in routine care (Proctor and others 2009). In the lan- ports the efficacy of brief interventions on harm from guage of universal health coverage, it is the difference drug use and the overall pattern of drug consumption, between contact coverage and effective coverage; that including drug abstinence. The brief intervention con- is, substantial improvement in access to care needs stitutes a single session of 5–30 minutes, incorporating to be accompanied by improvement in the quality of individualized feedback and advice on reducing or service delivery. The inadequacy of resources and low stopping cannabis/psychostimulant consumption, and priority given to MNS disorders might suggest that the offer of follow-up (NICE 2008). consideration of the quality of care is subservient to the In South Africa, the government has published quantity of available and accessible services. However, integrated guidelines for all primary health work- quality improvement (QI) mechanisms ensure that ers, including HIV/AIDS; major noncommunicable available resources are well-utilized, in the sense that diseases; and a range of mental health problems, those in contact with services actually derive appropri- including depression, anxiety, mania, substance abuse, ate benefit from evidence-based interventions. and psychosis. These guidelines, called Primary Care Moreover, good-quality services help to build people’s 101 (PC101) (DOH 2012), are used by the national confidence in making use of mental health care inter- Department of Health as part of a primary care revi- ventions, increasing the likelihood of seeking the care talization program to deliver integrated care within that they need (Funk and others 2009). Low-quality a chronic disease management framework (Asmall services lead people with MNS disorders to experience and Mahomed 2013). This approach includes con- human rights violations and discrimination in health solidating care for all patients with chronic diseases care settings. In many countries, the quality of care into a single care delivery point at the facility level in inpatient and outpatient facilities is poor or even and strengthening clinical decision support for nurses. harmful and can actively hinder recovery (The Health PC101 provides a set of clinical algorithms using a Foundation 2013). pragmatic signs-and-symptoms approach and inte- QI methods have been shown to be effective for grates detection and management of MNS disorders sustained scale-up and adaptation of standardized with other chronic conditions. The guidelines include treatment packages for Millennium Development Goal training materials delivered in a cascaded train-the- health priority areas. QI could be included as a routine trainer format and ongoing support for primary care part of mental health implementation and customiza- practitioners from trainers at the district and sub- tion (Patel and others 2013). Quality assurance (QA) district levels. At the community level, outreach teams involves the use of tools and logic to assess quality of community health workers are trained to support performance. QI is the use of methods to enhance clinically stable patients and self-care. quality performance. QA/QI is an integrative process for identifying current levels of quality and improving the quality of performance. QA/QI plays an important QUALITY OF CARE FOR MNS DISORDERS role in monitoring and improving the implementation Quality in health care has been defined by the IOM as of evidence-based practices; it also helps to monitor the degree to which health care services for individuals and improve the quality of training and supervision and populations increase the likelihood of desired health required for the delivery of services. Some important outcomes and are consistent with current professional QI approaches are continuous quality improvement, knowledge (IOM 2001). Good-quality care is effective, Lean, Six Sigma, Plan Do Study Act, Statistical Process efficient, equitable, timely, person centered, and safe, and Control, and Total Quality Management (The Health delivers a positive patient experience (IOM 2001). Foundation 2013). Despite the strong and growing knowledge base QI frameworks and guidelines for LMICs have been for delivery of mental health services, the treatment developed in the form of a WHO guidance package for gap for MNS disorders remains unacceptably large, QI in mental health services (WHO 2003b). The package with over 90 percent of people with mental disorders provides an integrated resource for the planning and in LMICs going without treatment (Kohn and others refining of mental health systems on a national scale 2004). This treatment gap is not just a quantitative (Funk and others 2009). In a quality framework, stan- phenomenon; it also contains an important quality dards and criteria are important tools for assessment 214 Mental, Neurological, and Substance Use Disorders and improvement. A standard is a broad statement of A comprehensive assessment of facilities based on the desired and achievable level of performance against these themes can help to identify problems in existing which actual performance can be measured. The criteria health care practices and to plan effective means to are measurable elements of service provision. Criteria ensure that the services are of good quality, respectful of relate to the desired outcome or performance of staff human rights, and responsive to the users’ requirements, or services. The standard is achieved when all criteria and promote the users’ autonomy, dignity, and right to associated with it are met. self-determination. Protection of human rights is a critical aspect of the quality of mental health care. The treatment provided in health care settings is often intended to keep people and CONCLUSIONS their conditions under control rather than to enhance This chapter has described the health care delivery their autonomy and improve their quality of life. People platform and its delivery channels and evidence-based can be seen as objects of treatment rather than human interventions. The key points for effective and efficient beings with the same rights and entitlements as every- delivery of mental health services are as follows: body else. They often are not consulted on their care or recovery plans; many receive treatment against their wishes. The situation in inpatient facilities is often far • To deliver interventions for MNS disorders, the focus worse: people may be locked away for weeks, months, and needs to move from vertical programs to horizontal even years in psychiatric hospitals or social care homes, health service platforms. where they can be subject to dehumanizing, degrading • The WHO pyramid framework of self-care, primary treatment, including violence and abuse (WHO 2003b). care, and specialist care continues to provide a use- WHO developed the QualityRights Toolkit to ful approach for understanding potential delivery assess and improve the quality of life and human channels. rights of people with MNS disorders receiving treat- • A set of evidence-based interventions within this ment in mental health and social care facilities (WHO framework can be identified for promotion and 2012). People living in these facilities are isolated prevention; identification and case detection; and from society and have little or no opportunity to treatment, care, and rehabilitation interventions. lead normal, fulfilling lives in the community. WHO • The delivery of these interventions requires an recommends that countries progressively close down approach that embraces public health, systems, and this type of facility and instead establish community- whole-government principles. based services and integrate mental health into pri- • The key strategies for this delivery are implement- mary care services and the services offered by general ing collaborative stepped care, strengthening human hospitals. Although this tool does not endorse long- resources, and integrating mental health into general stay facilities as an appropriate setting for treatment health care. and care, as long as these types of facilities continue • Finally, it is important not only to improve access to to exist all over the world, there is a need to promote health services, but also to focus on improving the the rights of those residing in them. quality of care delivered. The QualityRights Toolkit covers the following five themes drawn from the United Nations Convention on Recommendations for policy makers include the Rights of Persons with Disabilities: adopting these principles and strategies using a plat- formwide approach. Policy makers need to engage • Right to an adequate standard of living and social with a wide range of stakeholders in this process and protection make use of the best available evidence in a transpar- • Right to enjoyment of the highest attainable standard ent manner. of physical and mental health • Right to exercise legal capacity and the right to per- sonal liberty and security of person NOTE • Freedom from torture or cruel, inhuman, or degrad- Disclaimer: Dan Chisholm is a staff member of the World ing treatment or punishment and from exploitation, Health Organization. The author alone is responsible for the violence, and abuse views expressed in this publication, and they do not necessarily • Right to live independently and be included in the represent the decisions, policy, or views of the World Health community. Organization. Health Care Platform Interventions 215 This chapter was previously published as an article by Specialists in Low- and Middle-Income Countries: R. 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London: The Health Foundation. and Face Pain 54 (4): 601–09. doi:10.1111/head.12330. 218 Mental, Neurological, and Substance Use Disorders Chapter 12 Cost-Effectiveness and Affordability of Interventions, Policies, and Platforms for the Prevention and Treatment of Mental, Neurological, and Substance Use Disorders Carol Levin and Dan Chisholm INTRODUCTION Such assessments have often been conducted alongside clinical trials, enabling health economic researchers to Since the turn of the millennium, considerable progress add resource use questions to study protocols, generate has been made in developing an evidence base on which estimates of each trial participant’s health care costs, and interventions are effective and feasible for improving relate these costs to primary outcome measures in the mental health in low- and middle-income countries form of cost-effectiveness ratios. We review this type of (LMICs). Such evidence provides a critical input to economic evidence over the course of this chapter, with the formulation of plans and priorities to address the a particular focus on studies that have been successfully large and growing burden of mental, neurological, and carried out in LMICs. However, the number of com- substance use (MNS) disorders. However, for successful pleted studies remains small and insufficient to inform and sustainable scale-up of effective interventions and resource allocation decisions in all the national settings innovative service delivery strategies, decision makers where cost-effectiveness information would be valuable, require not only evidence of an intervention’s impact on including the many countries where informal or tradi- health and other outcomes, such as equity or poverty, tional health care represents the predominant model of but also evidence of its cost and cost-effectiveness. Cost service availability. This paucity of economic evidence data provide information relevant to the financial plan- reflects the overall lack of resources and infrastructure ning and implementation of prioritized, evidence-based for mental health services in LMICs, including research strategies; cost-effectiveness analysis indicates the rela- capacity. tive efficiency or value for money associated with inter- Partly to address the paucity of cost-effectiveness ventions or innovations. trials, as well as their intrinsic specificity to the setting The application of economic evaluation to MNS in which they are conducted, a broader, modeling-based disorders has largely focused on the assessment of approach has also been used to build up economic a specific intervention’s costs and health outcomes, evidence for international mental health policy and relative to some comparator, which may be treat- planning. This approach includes the earlier editions ment as usual, another innovation, or no intervention. of the Disease Control Priorities (DCP) project and Corresponding author: Carol Levin, Department of Global Health, University of Washington, Seattle, WA, United States; clevin@uw.edu. 219 the World Health Organization’s (WHO) CHOosing since 2000 in English. The search combined terms Interventions that are Cost-Effective (CHOICE) project. for specific mental health interventions with eco- Such model-based studies rely on existing data, as well nomic terms such as “cost,” “cost-effectiveness,” or as several analytical assumptions; these studies have “quality-adjusted life year (QALY),” as well as the adopted an epidemiological, population-based approach names of all LMICs and their respective regions (see that identifies the expected costs and health impacts of annex 12A for a list of search terms used to identify delivering evidence-based interventions at scale in the relevant literature). Where little or no literature was population as a whole, whether a specific country or found for LMICs on interventions of potential impor- an entire region. We also review this form of economic tance, this systematic search was augmented by selec- evidence and comment on important gaps in the current tive searches of the literature available since 1995 for evidence base, as well as the relative strengths and limita- high-income countries (HICs); however, these results tions of this approach. are not included in the figures or tables. Annex 12B One important limitation of conventional cost- provides the search statistics. effectiveness analysis—whether garnered through Articles included in the review were graded using the trial-based or model-based approaches—is that it is checklist of Drummond and others (2005) to generate a restricted to consideration of the specific implementa- quality score for each article, with most studies graded tion costs and health-related outcomes of an interven- between 7 and 10. Annex 12C provides a list of studies tion; it does not typically extend to the nonhealth or that were used to generate the tables and figures pre- wider economic or social value of investing in mental sented in this chapter. It presents detailed information health innovation and service scale-up. In particu- on the intervention characteristics and comparators, lar, cost-effectiveness analysis in its conventional form target population group, geographic location, method- has little to say about the equitable distribution of ology, results, and quality scores. All cost-effectiveness costs and health gains across different groups of the results are presented in 2012 US$ except where noted target population. Incorporation of such concerns into otherwise. Consistent with earlier iterations of DCP, economic evaluation represents a major objective of reported regional estimates refer to the World Bank’s extended cost-effectiveness analysis, which is explored categorization of countries by income. and addressed specifically in chapter 13 in this volume (Chisholm, Johansson, and others 2015). In this chapter, we review the available cost- COST-EFFECTIVENESS OF MENTAL HEALTH effectiveness evidence for the different levels and under- PROMOTION AND PROTECTION MEASURES pinning strategies of the mental health care system, AT THE POPULATION AND COMMUNITY with a focus on information generated in or for LMICs. Based on the overall analytical framework and priority LEVELS intervention matrices developed for this volume, the Economic evaluation has yet to be extensively applied to remainder of the chapter is presented as follows. First, mental health promotion, largely because of the chal- we consider the economic evidence for mental health lenges associated with using conventional methods and prevention and protection at the population and principles of cost-effectiveness analysis in the context community levels of the health and welfare system, of such programs, in particular, the limitations of exper- including legislative, regulatory, and informational mea- imental study design; the multifaceted, complex, and sures at the public policy level (population platform), long-term nature of anticipated program benefits; and as well as school-, workplace-, and community-based the shortage of sensitive or suitable outcome measures programs (community platform). We then examine the (Petticrew and others 2005). Moreover, many of the economic evidence relating to the identification and determinants of poor mental health and mental health treatment of MNS disorders (health care platform), inequalities lie outside the health sector, thereby requir- focusing on the relative cost-effectiveness or efficiency ing an evaluation of intersectoral action. Certain mental of treatment programs implemented in nonspecialized health promotion strategies are not amenable to con- versus more specialized health care settings. Finally, we trolled studies, because it is not feasible or ethical to assess the financial costs and budgetary implications of exclude a segment of the target population from exposure implementing or scaling up a set of prioritized, cost- to the intervention in question. Since cost-effectiveness effective interventions. is by definition a relative concept, this limitation makes Our review is based on available, published litera- estimation of the relative or comparative efficiency of one ture. A systematic search of the literature for LMICs strategy over another problematic. Where such compar- was undertaken in PubMed to find articles published isons are not possible, prospective observational studies, 220 Mental, Neurological, and Substance Use Disorders time-series analyses, or ecological studies within a single DALYs averted per US$1 million expenditure (reported population can still be conducted and may provide a suf- values have been updated to 2012 price levels). ficient basis for decision making. An alternative approach In lower-prevalence contexts, such as East Asia and is via modeling studies, which attempt to simulate empir- Pacific and South Asia, population-level effects drop ical studies on the basis of publicly available data sources. off and cost-effectiveness ratios rise accordingly. The Chapter 10 of this volume (Petersen and others 2015) impact of alcohol tax increases stands to be mitigated identifies a number of good and best practices for pro- by illegal production, tax evasion, and illegal trading, tecting mental health at the population and community which account for approximately 30 percent of all con- levels, including the following: sumption in European and Latin American subregions and up to 80 percent in certain parts of Sub-Saharan • Laws and regulations to reduce harmful alcohol use Africa. Reducing this unrecorded consumption by • Laws and regulations to reduce access to lethal means 20–50 percent via concerted tax enforcement efforts of suicide by law enforcement and excise officers is estimated to • School-based social emotional learning programs to cost 50–100 percent more than a tax increase, but it prevent the onset of mental disorders and promote produces similar levels of health gain in the popula- mental health in children and adolescents tion (Anderson, Chisholm, and Fuhr 2009). In settings • Community-based parenting programs, particularly with higher levels of unrecorded production and during infancy and early childhood consumption, such as India, increasing the proportion • Training programs to help gatekeepers to identify of consumption that is taxed may be a more effective people with mental illness. pricing policy than simply increasing the excise tax; excise tax increases may only encourage further illegal We consider the economic evidence for each of production, smuggling, and cross-border purchases these policy options. Clearly, there are other potential (Patel and others 2011). approaches that can be tested and adopted that can help The impact of reducing access to retail outlets for to promote and protect mental health. For example, cash specified periods of the week to limit the availability and transfers and microfinance have been used to support implementing a comprehensive advertising ban to limit the health of women and children in several settings and the marketing of alcoholic beverages have the potential have the potential to improve mental health outcomes to be very cost-effective countermeasures, but only if such as cognitive development in young children. Better they are fully enforced; compared with doing nothing, understanding of the impact and costs of cash transfers each DALY averted costs between US$200 and US$1,200 and other social programs, such as microfinance, is (Rehm and others 2006). For impaired-driving policies essential for addressing the cycle of poverty and mental and countermeasures, there is good evidence from HICs disorders (Lund and others 2011). on the effectiveness of impaired-driving laws and their enforcement via roadside breath testing and check- points. The estimated cost-effectiveness of such coun- Laws and Regulations to Reduce Harmful Alcohol Use termeasures in LMICs ranges from US$800 to US$3,000 Population-based measures for reducing the demand per DALY averted. However, the applicability—and for or access to alcohol include fiscal instruments (excise by extension, the cost-effectiveness—of such measures taxes), legal limits (minimum drinking age, maximum may be limited in settings where large segments of the blood alcohol content levels when driving), and regu- population do not drive or where noncommercial alco- lation (advertising bans and restricted access to retail holic home brews represent the predominant form of outlets). Within the category of pricing policies, consistent consumption. evidence shows that the consumption of alcohol is Country-level information on the cost-effectiveness responsive to an increase in final prices, and this can be of legislation to control alcohol use is limited, with only effectuated via higher excise taxes on alcoholic beverages. one study conducted in a low-income setting. A country Tax increases of 20 percent or even 50 percent represent contextualization study of the WHO-CHOICE model a highly cost-effective response in countries with a high in Nigeria, a lower-middle-income country, showed that prevalence of heavy drinking, defined as greater than alcohol taxation does generate appreciable health gains. 5 percent of adults. For example, Rehm and others (2006) However, these gains did not result in a significant estimated that in LMICs in Europe and Central Asia, improvement in cost-effectiveness, because it was expected Latin America and the Caribbean, and Sub-Saharan that an increase in taxes would lead to a rise in the amount Africa, a disability-adjusted life year (DALY) can be of illicit and untaxed consumption of alcohol. The study averted for US$200–US$400, equivalent to 2,500–5,000 did find that implementation of random roadside breath Cost-Effectiveness and Affordability of Interventions, Policies, and Platforms 221 testing for alcohol could potentially generate considerably (Knapp and others 2011; McCabe 2007). Although more healthy life years than could other interventions and such life skills programs seem to represent good value would do so at a lower cost (Gureje and others 2007). for money, there is a need to ascertain this via formal cost-effectiveness studies on specific early childhood development and classroom-based educational strate- Laws to Restrict Access to Means of Self-Harm and gies, even in HICs (Barry and others 2009; Mihalopoulos Suicide and others 2011). There is a paucity of robust economic studies to inform A recent randomized control trial (RCT) on policy makers about the budgetary requirements and classroom-based cognitive behavioral therapy (CBT) return on investment associated with scaled-up efforts for reducing symptoms of depression in adolescents to prevent self-harm or suicide (Zechmeister and others found that despite high levels of fidelity and adherence, 2008). A recent WHO review of suicide prevention strat- a universally provided CBT depression prevention egies that included cost as a parameter of interest, how- program was not cost-effective, in part because of the ever, showed that two-thirds of the strategies assessed relatively high cost per student and the marginal gain as being effective or promising were categorized as low in health outcomes (Anderson and others 2014). In cost; low cost was also closely associated with universal Chile, an HIC, a similar school-based RCT was imple- or selective, as opposed to more indicated or targeted, mented that compared a CBT depression prevention prevention approaches (WHO 2010). Australia’s ACE- program with usual care with enhanced counseling; Prevention (Assessing Cost-Effectiveness in Prevention) the results indicated that the program was not effec- project assessed the cost-effectiveness of reducing access tive compared with usual care (Araya and others to means via revised legislation for gun ownership 2011). In India, peer education and teacher training and estimated that the cost per healthy life year gained in educational institutions that was provided as part would exceed US$57,000; guidelines for more responsi- of a multicomponent, population-based youth health ble media reporting would cost US$30,800 per healthy promotion intervention had limited feasibility and life year gained if at least one suicide is averted (Vos and effect because of several logistical and financial barri- others 2010). ers (Balaji and others 2011). In Mauritius, evaluation Partly to address this paucity of available evidence, of a school-based prevention program for adolescent an extended cost-effectiveness analysis was undertaken depression showed short-term benefits to depression, for this volume relating to a pesticide ban in India to hopelessness, coping skills, and self-esteem, but its prevent self-harm and suicide, based on the experience sustainability has yet to be ascertained (Rivet-Duval, of Sri Lanka’s ban on pesticides in the 1990s (Nigam and Heriot, and Hunt 2011). others 2015). The authors estimated that 3,750 deaths These study findings can offer insights about which could be averted per year if 80 percent of the population interventions are most likely to be acceptable and fea- no longer had access to endosulfan, a commonly used sible as well as effective in the long term. In particular, Class II pesticide. Implementation of the ban plus hos- it seems that the cost-effectiveness of more intensive, pital treatment for self-harm cases was estimated to cost individual-based approaches such as CBT can be adversely US$0.10 per capita, yielding a cost-effectiveness ratio of affected by the cost of their implementation. close to US$1,000 per life-year gained (Nigam and others 2015). However, the analysis did not take into account costs potentially falling to other sectors or agents as a Community-Based Parenting Programs result of the ban, or potential substitution effects. Systematic reviews show that early child development and parenting skills training are effective in enhancing the cognitive and social skills of children under age School-Based Social Emotional Learning Programs five years, and the training promotes mental and social Integrated mental health promotion programs in schools development (Mejia, Calam, and Sanders 2012; Merry targeting children and adolescents have long-term and others 2012). Such programs are provided on a benefits, including improved emotional and social func- group, individual, or self-administered basis in a variety tioning and academic achievement (Tennant and others of settings, including health clinics, community centers, 2007; Weare and Nind 2011). Furthermore, economic and schools, by different types of providers, such as analyses from HICs indicate that social emotional learn- health visitors, social workers, and psychologists. These ing (SEL) interventions in schools are cost-effective, differences influence the cost and cost-effectiveness of resulting in savings from better health outcomes, as well parenting programs. Studies in the United Kingdom as reduced expenditure in the criminal justice system indicate little difference between community-based and 222 Mental, Neurological, and Substance Use Disorders hospital-based implementations of this kind of program via three key delivery channels: self-care and informal (Cunningham, Bremner, and Boyle 1995; Harrington health care; primary health care; and specialist health and others 2000). care. Chapter 11 also identifies several core strategies Cost-effectiveness studies in LMICs have yet to be for strengthening the capacity of mental health systems conducted, but analyses in HICs indicate that such pro- through collaborative care, task sharing, and integration grams are cost-effective and pay for themselves if the with existing health programs. The cost-effectiveness averted costs of future ill-health are taken into account. literature relating to care and treatment for MNS disor- In Australia, for example, Mihalopoulos and others ders is reviewed here in terms of these delivery channels (2007) assessed the costs and benefits of a stepped, mul- and health system–strengthening strategies. tidisciplinary preventative family intervention called Positive Parenting Program (Triple P). The intervention is designed to prevent behavioral disorders in children Self-Care and Informal Health Care by increasing parenting knowledge and skills and foster- The evidence base on innovative methods that provide ing emotional competence in children; the researchers an alternative to facility-based services and have the found that the intervention costs less than the amount potential to increase access to cost-effective treatment it saves, until the reduction in prevalence of conduct and care in LMICs remains relatively sparse. Yet such disorder falls below 7 percent, at which point net costs innovation will be essential to overcome the inadequate become positive. Similarly, in the United Kingdom, supply of and access to mental health specialists (Patel parenting programs are expected to be cost saving, with and others 2010). With the greater support for and diffu- gross savings exceeding the average cost of the interven- sion of global mental health research and innovation in tion by a factor of 8 to 1 (Knapp, McDaid, and Parsonage alternative models, such as case detection by community 2011). Since studies from HICs show such promise, it members and self-care via e-health or other technolo- will be important to determine the feasibility, impact, gies, greater awareness of the potential impact of such and costs of these programs in lower-resourced settings. innovations is emerging (http://mhinnovation.net). Evidence on the known effectiveness, feasibility, or cost-effectiveness remains limited for the purposes Programs to Train Gatekeepers to Identify People with of informing program design. Even in HICs where Mental Illness systematic reviews of the efficacy, acceptability, and As discussed in chapter 10 in this volume (Petersen and affordability of these approaches have been conducted, others 2015), mental health first aid training is com- cost-effectiveness has not received significant attention. monly used at the community level to promote identifi- For example, despite a growing number of e-health and cation and case detection. For example, training of police self-help randomized clinical trials conducted in HICs officers can reduce stigma and improve care for people in the past decade, most studies fail to provide infor- with MNS disorders (Krameddine and others 2013). mation on long-term clinical benefits, acceptability, or There are no studies of the cost-effectiveness of such cost-effectiveness. This lack limits the usefulness of the programs in LMICs; however, a study from Canada studies for LMICs, which have more fragmented access showed that a one-day training course significantly to web-based information (Lewis, Pearce, and Bisson increased the recognition of mental health issues, 2012; Martinez and others 2014; van Boeijen and others improved efficiency in dealing with mental health issues, 2005). An example of the kind of information that can and decreased the use of weapons or physical interac- be garnered from economic evaluation of these tech- tions with individuals who were mentally ill. The train- nologies is a Swedish cost-effectiveness trial of Internet- ing cost was US$120 per officer but led to significant versus group-based CBT for persons with social anxiety cost savings of more than US$80,000 in the following six disorders (Hedman and others 2011). The study found months (Krameddine and others 2013). that both interventions reduced overall societal costs appreciably and delivered similar health benefits to the target population; however, because the Internet-based COST-EFFECTIVENESS OF CARE AND CBT is less costly, it is the more cost-effective option. TREATMENT FOR MENTAL, NEUROLOGICAL, The relative cost-effectiveness of traditional and complementary systems of medicine in the treatment AND SUBSTANCE USE DISORDERS of MNS disorders, vis-a-vis established biopsychosocial Chapter 11 in this volume (Shidhaye, Lund, and models of care, has not been evaluated, despite the fact Chisholm 2015) discusses health care services as a deliv- that such systems of care are widely available and used in ery platform for improving population mental health LMICs (Gureje and others 2015). This lack of evaluation Cost-Effectiveness and Affordability of Interventions, Policies, and Platforms 223 reflects the highly heterogeneous nature of the practices A summary of country-level cost-effectiveness studies undertaken, as well as a lack of established efficacy for that report on the cost per healthy life year gained is them. Estimation of the costs and outcomes associated shown in figure 12.1 and annex 12D. with a collaborative model of care involving the liaison between traditional and allopathic systems of medicine National Studies represents an important if challenging research question, One of the first depression trials to include an economic especially in countries or regions where the practice of dimension in LMICs was a stepped care, multicomponent traditional medicine prevails. program in Chile. The program comprised group inter- vention, monitoring of clinical progress and medication compliance, and coordinating of further management Primary Health Care with primary care physicians (Araya and others 2006). With the increasing attention to mental health care in The program was implemented by trained non-physician LMICs and growing evidence that improvements can health care workers and assessed the cost-effectiveness of be achieved with limited resources and impoverished a task-shifting, stepped care approach to treatment. The populations, there has been a rise in country-level results indicated that the innovative program was sig- economic evaluations. Most of the economic analyses to nificantly more effective than the usual care of physician date have been directed to the treatment of mental disor- consultations combined with the prescription of antide- ders in health care settings, particularly for mood (affec- pressants only and the program was achieved at a modest tive) disorders, such as depression, and nonaffective cost increase; it is now a nationally supported program. psychotic disorders, such as schizophrenia; trial-based In India, a study of a task-shifting approach to the and model-based evaluations have been undertaken. treatment of depression and/or anxiety (MANAS trial) Figure 12.1 Country-Specific Cost-Effectiveness of MNS Interventions (cost per disability-adjusted life year averted or healthy life year gained, 2012 US$) Schizophrenia Facility-based treatment with older (neuroleptic) antipsychotic drug 1,427 (Brazil; Lindner and others 2009) Facility-based psychosocial treatment with neuroleptic antipsychotic drug 1,774 (Nigeria; Gureje and others 2007) Episodic treatment in primary care with newer SSRI drug (Thailand; Prukkanone and others 2012) 1,670 Episodic treatment in primary care with older TCA drug (Nigeria; Gureje and others 2007) 2,048 Maintenance treatment in primary care with newer SSRI: fluoxetine Depression 1,511 (Thailand; Prukkanone and others 2012) Continuation treatment in primary care with newer SSRIs 1,312 (Thailand; Prukkanone and others 2012) Episodic psychosocial treatment in primary care (Thailand; Prukkanone and others 2012) 914 Maintenance psychosocial treatment in primary care (Thailand; Prukkanone and others 2012) 437 Heavy Epilepsy Older anti-epileptic drug in primary care: 50% coverage 279 (Nigeria; Gureje and others 2007) alcohol Impaired-driving laws and enforcement via breath testing use 236 (Nigeria; Gureje and others 2007) $1 $10 $100 $1,000 $10,000 Note: ** = effects measured in quality-adjusted life years gained; all other effect estimates are measured as disability-adjusted life years averted; MNS = mental, neurological, and substance use; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant. All reported cost-effectiveness estimates have been converted to 2012 US$. 224 Mental, Neurological, and Substance Use Disorders involved trained lay health workers to provide psycho- antidepressants depends on the relative effectiveness of social interventions as part of primary care. The inter- the choice of drugs, but it is likely determined by budget vention was found to be cost-effective and cost saving, constraints, pricing policies, and relative hospital costs and it overcame barriers posed by a shortage of mental (Machado and others 2008). health professionals (Buttorff and others 2012). In Nigeria, treating schizophrenia had higher costs In other country studies, a modeling approach has per treated case; however, given the larger proportion of been used to inform decisions on priority setting and the population suffering from depression, the total costs resource allocation. In Thailand, lower cost yet equally for treating depression were higher (Gureje and others effective generic antidepressants and CBT were found to 2007). Cost-effective treatment options for schizophre- be cost-effective interventions in the acute, continuation, nia include community-based interventions that com- and maintenance treatment phases of depression up to bine older antipsychotic drugs with psychosocial five years after its onset (Prukkanone and others 2012). treatment or case management. The use of newer atypi- Maintenance treatment using CBT was the single-most cal antipsychotic drugs without supportive psychosocial cost-effective strategy, but this finding has to be balanced therapy was found to be the least cost-effective treatment against the shortage of trained mental health personnel strategy. available to deliver psychotherapy services. Applying The literature offers very little guidance for what may the same methodological approach to schizophrenia, be cost-effective for other MNS disorders in LMICs, such Phanthunane and others (2011) showed that despite as dementia, drug use disorders, and childhood disorders. the higher costs of including family psychoeducation, The limited economic evaluations for dementia have the inclusion of this psychosocial support element been conducted in HICs, focusing on burden and mood, increases adherence to and outcomes from medica- with only a few studies capturing health gains expressed tion and is the most cost-effective option. Analysis of as QALYs (Jones, Edwards, and Hounsome 2012). In the these factors helped Thailand to prioritize a strategy United Kingdom, for example, a manual-based coping to use generic newer drugs as the first-line treatment, strategy program for promoting the mental health of ideally in combination with family interventions, to caregivers of people with dementia was found to be increase health gains and lower hospitalization costs cost-effective in cost per QALY terms (Livingston and (Phanthunane and others 2011). others 2014). For attention-deficit hyperactivity disorder In Brazil, where differences in unit prices between (ADHD), consistent evidence from HICs demonstrates older and newer drugs are more marked than in HICs and that drug therapy is cost-effective compared with no hospitalization costs are relatively low, cost-effectiveness treatment or behavioral therapy. None of the cost- and budget impact analyses have been conducted to effectiveness studies were relevant for adults, in whom select the most feasible and affordable drug therapy for ADHD is a growing concern, or for long-term cost- the treatment of schizophrenia and depression. The use effectiveness beyond six months (King and others 2006; of newer atypical antipsychotic drugs for schizophre- Wu and others 2012). nia reduces the probability of hospitalization. But the Very little evidence is available for parent training and analysis for Brazil found older neuroleptic drugs to be education programs for childhood disorders, although the more cost-effective strategy overall (Lindner and these may also offer cost-effective solutions for conduct others 2009). For depression, drug costs represent a disorder (Dretzke and others 2005). ADHD and demen- smaller share of the economic cost and did not affect the tia are characterized by a high economic burden on care cost-effectiveness across competing alternatives. A bud- systems and caregivers of children, adolescents, and the get impact analysis suggested that the addition of elderly. Evidence shows there is an increase in the indi- serotonin-norepinephrine reuptake inhibitors (SNRIs) rect costs to caregivers in terms of increased absenteeism for treating depression could generate cost savings to the and lost productivity associated with managing a family health care system, given the overall lower average cost member’s care (Matza, Paramore, and Prasad 2005). per patient treated (Machado and others 2007). Findings from HICs are not necessarily transferable to In Colombia, a cost-effectiveness analysis of three LMICs, given the differences in the recognition, diag- classes of antidepressants showed that the older tricyclic nosis, and health care system costs. Yet, as demographic antidepressants had greater effectiveness and lower costs and economic transitions occur, dementia and disorders compared with the newer selective serotonin reuptake in childhood and adolescence are likely to rise in promi- inhibitors and SNRIs. Colombia’s lower hospitalization nence (Albanese and others 2011). costs compared with Brazil’s were the more important There is also a dearth of economic evidence to cost driver, and in this setting, the drug costs had a guide and support drug policy and resource allocation minimal impact. In summary, the cost-effectiveness of decisions. Even in HICs, evidence is restricted to one Cost-Effectiveness and Affordability of Interventions, Policies, and Platforms 225 or two studies of specific treatment modalities, such psychotic disorders, which are now produced in several as substitution or maintenance treatment of opioid countries under nonbranded, generic licenses and can dependence. In Australia, for example, methadone be purchased for approximately 10 times less than a maintenance treatment and buprenorphine mainte- decade ago. nance treatment were found to lead to appreciable As long as these lower, generic prices of newer increases in heroin-free days at an acceptable and antidepressant and antipsychotic medications are not significantly different level of cost-effectiveness sought out and applied, the previously demonstrated (Doran 2005; Harris, Gospodarevskaya, and Ritter cost-effectiveness superiority of interventions using 2005). In countries where the spread of HIV is older drugs for treating schizophrenia and depression being fueled by injecting drug users, methadone essentially disappears, meaning that there is little maintenance programs can also be an effective and reason to choose between them on efficiency grounds cost-effective strategy for HIV prevention, as evi- (see table 12.1). What remains clear, however, is that denced by a study undertaken in Belarus, where the drug treatment alone does not constitute the most average cost per averted HIV infection was projected cost-effective option for treating mental disorders; at less than US$500 (Kumaranayake and others 2004). rather, it is the combination of pharmacological and psychosocial treatment that leads to the best overall International Studies balance of cost and health outcome for severe mental Cost-effectiveness modeling has also been conducted disorders. at the regional and international levels. Although these Across the six regions considered, the average cost levels lack specificity to a national decision-making per healthy life year gained for such a combination context, they can inform priority-setting agendas at strategy—the most cost-effective of the strategies the national and international levels, including invest- considered—ranges from US$3,300 to US$14,000 for ment decisions by donors and nongovernmental schizophrenia and bipolar disorder. For depression, organizations. treatment in primary health care on an episodic basis The primary source of evidence for MNS disor- costs between US$800 and US$3,500 per healthy life ders to date comes from the WHO-CHOICE program year gained; for a little more cost, as well as more overall (Chisholm 2005; Chisholm and Saxena 2012; Hyman health gain in the population, treatment on a proactive, and others 2006). An advantage of the WHO-CHOICE maintenance basis is also a cost-effective alternative, approach is its application of a consistent methodology, because so many persons experience recurrent episodes which enables like-with-like comparisons to be made (US$1,300–US$4,900 per healthy life year gained). between different disorders and geographical regions. Differences in cost per healthy life year gained are largely Table 12.1 shows the comparative cost-effectiveness of a driven by the cost of labor and contacts with the health range of interventions for addressing MNS disorders in care system (relatively higher in Latin America and the different regions of the world, relative to a situation of Caribbean and relatively lower in Sub-Saharan Africa no intervention. Because each intervention is compared and South Asia). with a situation of no treatment, the resulting metric Other disorders that can be appropriately managed is called an average, as opposed to incremental, cost- in nonspecialist health care settings and that have effectiveness ratio. been subjected to economic evaluation cover neuro- The results are reported for six geographically distinct logical disorders (epilepsy and migraine) and substance groupings of LMICs that are used by the World Bank for use disorders (harmful alcohol use). WHO-CHOICE reporting purposes. Inevitably, such country groupings analyses conducted for these disorders, again updated contain substantial sociocultural as well as economic to 2012 prices, indicate that they are at least as cost- heterogeneity, which limits their applicability to partic- effective to treat as the aforementioned mental disorders ular contexts or populations. Previously published and (Chisholm 2005; Linde, Chisholm, and Steiner 2015; updated findings (Chisholm and Saxena 2012; Hyman Rehm and others 2006). Table 12.1 indicates that a year and others 2006) have been converted here to 2012 US$ of healthy life can be obtained for less than US$1,000 values, based on International Monetary Fund inflation by offering brief interventions to persons with alcohol estimates, to enable comparison with other cost and use disorders, and for between US$600 and US$2,500 cost-effectiveness information presented in this and by treating epilepsy with first-line anti-epileptic drugs. other DCP-3 volumes. The exception to this price con- For migraine, a recent multicountry study using WHO- version process relates to newer psychotropic medica- CHOICE methods has been completed and is high- tions, such as fluoxetine for depression or risperidone for lighted in box 12.1. 226 Mental, Neurological, and Substance Use Disorders Table 12.1 Regional Cost-Effectiveness of Interventions for MNS Disorders (cost per disability-adjusted life year averted or healthy life year gained, 2012 US$) World Bank region Latin Sub- America Middle East Europe and East Saharan and the and North Central South Asia and Disorder: intervention Africa Caribbean Africa Asia Asia Pacific Schizophrenia SCZ-1: community-based treatment with older 8,390 20,465 21,263 13,799 4,915 5,688 (neuroleptic) antipsychotic drug SCZ-2: community-based treatment with newer 7,978 18,961 19,755 12,891 4,718 5,414 (atypical) antipsychotic drug SCZ-3: community-based treatment with older 6,005 13,858 14,413 11,396 3,490 3,865 antipsychotic drug + psychosocial treatment SCZ-4: community-based treatment with newer 6,014 13,649 14,192 11,233 3,523 3,890 antipsychotic drug + psychosocial treatment Bipolar disorder BIP-1: community-based treatment with older mood 4,571 14,261 12,120 9,999 3,392 4,402 stabilizer drug (lithium) BIP-2: community-based treatment with newer mood 7,930 16,470 13,911 12,339 5,047 5,839 stabilizer drug (valproate) BIP-3: community-based treatment with older mood 4,516 13,292 11,440 9,329 3,281 4,136 stabilizer drug + psychosocial care BIP-4: community-based treatment with newer mood 7,583 15,287 13,094 11,426 4,784 5,434 stabilizer drug + psychosocial care Depression DEP-1: episodic treatment in primary care with older 1,410 3,491 3,171 2,668 786 899 antidepressant drug (TCAs) DEP-2: episodic treatment in primary care with newer 1,395 3,361 3,057 2,456 788 894 antidepressant drug (SSRIs) DEP-3: episodic psychosocial treatment in primary care 2,189 4,838 4,594 2,724 1,161 1,223 DEP-4: episodic psychosocial treatment + older 2,083 4,427 4,232 2,722 1,128 1,178 antidepressant DEP-5: episodic psychosocial treatment + newer 2,144 4,477 4,285 2,660 1,167 1,218 antidepressant DEP-6: maintenance psychosocial treatment + older 2,461 4,866 4,783 3,225 1,315 1,373 antidepressant DEP-7: maintenance psychosocial treatment + newer 2,532 4,927 4,847 3,137 1,367 1,425 antidepressant Alcohol use disorders ALC-8: brief physician advice in primary care 407 878 — 494 684 332 Epilepsy EPI-1: older anti-epileptic drug in primary care 694 1,511 1,450 2,516 600 1,057 EPI-2: newer anti-epileptic drug in primary care 1,884 2,854 2,877 4,115 1,639 2,249 Sources: Chisholm and Saxena 2012; Hyman and others 2006. Note: MNS = mental, neurological, and substance use; TCAs = tricyclic antidepressants; SSRIs = selective serotonin reuptake inhibitors; — = not available. Cost-Effectiveness and Affordability of Interventions, Policies, and Platforms 227 Box 12.1 Cost-Effectiveness of Interventions for Migraine A WHO-CHOICE (World Health Organization– life year gained ranged from less than US$100 for CHOosing Interventions that are Cost-Effective) acute management with simple analgesics to thou- analysis was conducted for a selected core set of sands or even tens of thousands of US$ for treat- interventions for migraine in four countries: China, ment of analgesic nonresponders with triptans. India, the Russian Federation, and Zambia. The analysis included first-line analgesics, such as acetyl- The most cost-effective strategy by far is acute man- salicylic acid 1,000 milligrams (mg), and second-line agement with simple analgesics; it was less than medications, such as sumatriptan 50 mg, for acute US$100 per disability-adjusted life year averted and treatment of attacks. It was assumed that the latter therefore represents a highly cost-effective use of would be used only by nonresponders to first-line resources for health. Adding consumer education medications (a stepped care treatment paradigm). and improving adherence has a small upward influ- The analysis included prophylactic drugs, such as ence on cost-effectiveness. Compared with no treat- amitriptyline 100 mg daily. The expected conse- ment at all, this strategy is less than US$150 per quences of adding consumer education, in the form healthy life year gained; compared with use of simple of posters and leaflets in pharmacies explaining how analgesics without consumer education, the incre- to acquire and use these medications, and train- mental cost to be paid to obtain one extra healthy life ing for health care providers were also modeled. year rises to US$600. Compared with no treatment, the cost per healthy Source: Linde, Chisholm, and Steiner 2015. Specialist Health Care the basis of expected cost savings; inadequate expenditure Specialized mental health care covers hospital-based on community-based care is quite likely to result in poor outpatient and inpatient care for acute and severe outcomes for the individuals and families concerned episodes or cases of mental disorder. In many LMICs, (Knapp and others 2011). mental hospitals absorb a disproportionate share of the Detailed analysis of this kind has not been conducted government mental health budget—over 70 percent in the context of ongoing efforts to relocate services in in many cases—yet such institutions are commonly LMICs. However, a simple comparison of the cost of a associated with isolation, human rights violations, and community-based versus hospital-based service model poor outcomes. Such expenditure patterns also curb has been carried out as part of the WHO-CHOICE the development of more equitable and cost-effective analysis for schizophrenia and bipolar affective disorder. community-based services. For schizophrenia, the costs of the hospital-based ser- The dramatic deinstitutionalization observed in vice model exceeded those of the community-based most HICs in recent decades has been accompanied service model by 33–50 percent, reflecting greater use of by a certain amount of economic research into the resource-intensive services, such as acute and long-term costs, needs, and outcomes of persons relocated into psychiatric inpatient care (Chisholm 2005; Chisholm community-based care. Such research has shown that and others 2008). Even if one assumes no improved out- community-based care is certainly associated with better comes for persons treated under the community-based health and social outcomes, and it is not inherently more service model, there is a clear difference in terms of costly than institutions, once account is taken of indi- cost-effectiveness; the costs of the community-based viduals’ needs and the quality of care (Knapp and others service model are 25–40 percent lower. 2011). New community-based care arrangements could Relocating services and resources away from long- be more expensive than long-stay hospital care, but they stay mental hospitals toward nonspecialized health set- may still be seen as more cost-effective because, when tings is a key financing issue for mental health systems. appropriately set up and managed, they deliver better Efforts to change the balance of mental health care are health and economic outcomes. Accordingly, such a pro- often hindered by a lack of appropriate transitional cess of deinstitutionalization should not be predicated on funding. Transitional or dual funding is required over a 228 Mental, Neurological, and Substance Use Disorders period of time to build up appropriate community-based Figure 12.2 Cost of Scaling Up Population-Based Alcohol Control services before residents of long-term institutions can be Measures in Low- and Middle-Income Countries relocated. It is crucial to present an evidence-based case for relocating the locus of care, not only on the grounds 0.90 of equity, human rights, and user satisfaction, but also 0.80 Cost per capita (2012 US$) on the grounds of financial feasibility over a defined 0.70 transitional period. 0.60 0.50 0.40 AFFORDABILITY: COSTS OF INTERVENTION 0.30 SCALE-UP 0.20 The finding that interventions for the prevention and 0.10 treatment of a range of MNS disorders have been 0 cost-effective in LMICs does not necessarily translate Low-income countries Lower-middle-income Upper-middle-income (N = 13) countries (N = 13) countries (N = 16) into their affordability, especially given very low budget allocations for mental health. In addition to evidence on Lower interquartile Minimum Median the effectiveness and cost-effectiveness of different pol- Maximum Upper interquartile icy or treatment options, therefore, information is also Source: WHO 2011. needed on the feasibility and acceptability of interven- Note: N = number. tions, including their financial feasibility or affordability. In this section, we provide estimates of the expected methods to three illustrative countries from these differ- costs of scaling up the delivery of a set of cost-effective ent income strata—Ethiopia, India, and Mexico—yields policies and intervention strategies, including demand similar results (US$0.06, US$0.10, and US$0.24, respec- reduction measures for harmful alcohol use at the pop- tively). Although such per capita costs indicate that these ulation level, school-based mental health promotion at strategies are inherently affordable, total costs can add up the community level, and treatment of priority MNS quickly. This is particularly the case in larger countries, disorders in nonspecialized health care settings. such as Nigeria, where government policies that increase taxation on alcohol are expected to cost US$13 million per year, and policies such as roadside breath testing are Demand Reduction Strategies for Harmful Alcohol Use expected to cost even more (US$25 million per year at The economic evidence presented earlier in this chapter 80 percent coverage) (Gureje and others 2007). indicates that the most cost-effective strategy for reducing alcohol consumption is raising taxes or prices on alcohol products, followed by banning alcohol advertising, Social Emotional Learning Programs restricting access to alcohol, and enforcing dri nking and As documented in chapter 10 in this volume (Petersen driving legislation. Analysis of the costs of scaling up and others 2015), sufficient evidence exists from LMICs these interventions in LMICs was undertaken by the and HICs to consider universal and targeted SEL pro- WHO in preparation for the High-Level Meeting on grams as best practice policies for countries to imple- Non-communicable Diseases (WHO 2011). The overall ment. This finding is particularly true when teachers and annual cost per capita of implementing the constituent school counselors can be trained to deliver these inter- elements of an alcohol demand reduction strategy was ventions by integrating social and emotional learning estimated for countries with low versus middle incomes. and life skills development in life orientation curricula. The median cost ranges from less than US$0.10 per capita The cost of implementing school-based SEL interven- for low-income countries (LICs) and lower-middle-income tions in the context of LMICs has not yet been estimated, countries to around US$0.25 for upper-middle-income so an analysis was undertaken for the specific purpose of countries (figure 12.2). These costs are driven by this volume for a selection of countries—Ethiopia, India, human resource needs for program management and Mauritius, and Mexico—using methods already devel- enforcement of alcohol-related laws and policies, as well oped for micro-costing of population-based alcohol as media-related expenses. control strategies (WHO 2011). In addition, the analysis The variability around the median cost of implemen- used data from a psychosocial intervention to prevent tation results from large intercountry differences in the depression in adolescents ages 12 to 16 years in Mauritius prevalence of alcohol use. Application of the same costing (Rivet-Duval, Heriot, and Hunt 2011). The Resourceful Cost-Effectiveness and Affordability of Interventions, Policies, and Platforms 229 Adolescent Programme–Adolescent version (RAP-A) and services capable of improving mental health and showed that 11 hourly psychosocial sessions led to short- related outcomes. Accordingly, an essential element term benefits to depression, hopelessness, coping skills, of evidence-based mental health service planning and and self-esteem; benefits to coping skills and self-esteem scale-up relates to an assessment of what resources are were sustained at follow-up after six months. required to deliver services to the population in need and For costing this intervention, we assessed the annual to meet program goals. However, the lack of complete budgetary impact associated with the implementation or reliable local epidemiological and resource data has of the program among all 12-year-olds in the local often thwarted such efforts in many countries, although population, who make up 0.8–1.4 percent of the total that is changing with the generation of national mental population in the selected countries. The health educa- health profiles (see, for example, WHO’s mental health tors, who are teachers, are assumed to work full-time on ATLAS database, http://apps.who.int/globalatlas). this program, visiting and delivering the intervention at Empirical studies offer insights into average treatment different schools within municipalities or districts (six costs for depression and schizophrenia, when using sessions per day). If teachers deliver the RAP-A program medication alone or in combination with psychotherapy on a part-time basis, training costs—which include (annex 12E). Using older antidepressant drugs and pro- training of trainers at the national level and subnational viding stepped care tailored to the needs of patients has courses each year for the health educators—will be relatively low annual costs per case of depression, from higher. For every set of 20 health educators, we included US$107 in India to less than US$200 in Nigeria (Buttorff one supervisor; central administration and program and others 2012; Gureje and others 2007). Similarly, management costs were also included. the annual cost per treated case of epilepsy is relatively Based on 220 school days per year and 20 students low; in Nigeria, older anti-epileptic drugs are less than per session, 1.7–2.8 full-time health educators would be US$100 per patient per year. Schizophrenia is generally needed to deliver the intervention at scale for a district of more expensive to treat per person, using drug therapy one million persons (table 12.2). Country-specific unit alone, than either depression or epilepsy. Schizophrenia cost estimates taken from the WHO-CHOICE database treatment costs are more likely to vary widely across (http://www.who.int/choice/costs) were used to place countries, depending on the combination of inpatient a monetary value on these various resource inputs. and outpatient treatment and the antipsychotic medica- The resulting cost of implementing this program at full tions used. scale (100 percent coverage) ranges from US$0.03 per In Nigeria, treating schizophrenia with older antipsy- head of population in Ethiopia and India to US$0.11 chotic drugs falls between US$200 and US$300; newer in Mexico and US$0.24 in Mauritius, reflecting higher antipsychotic drugs cost more than US$6,000 per year. In salary and other input costs. These findings indicate Brazil, treatment with older, first-generation antipsychotic that school-based SEL interventions represent a low-cost drugs is as low as US$120 per patient per year; sec- strategy for promoting adolescent mental health. More ond-generation drugs cost more than US$4,000 per information about and evaluation of the long-term effec- person annually (Lindner and others 2009). In Thailand, tiveness of programs such as RAP-A is needed. direct medical costs for drug treatment in combination with family interventions are US$764 per patient per year. The variability in costs per person treated is in part due Mental Health Care in Nonspecialized Treatment to the small number of studies that have explored the Settings costs of different combinations of interventions and are Successful scaling up of mental health services not necessarily comparable. Accordingly, the studies are involves putting together a range of human, physi- not particularly useful for estimating the total cost of an cal, and other resource inputs to deliver interventions essential package of mental health services. Total costs also Table 12.2 Cost of Implementing Resourceful Adolescent Programme–Adolescent Version in Four Countries Cost item Ethiopia India Mexico Mauritius Total population age 12 years (%) 1.4 1.1 1.0 0.8 Health educators needed per 1 million population 2.8 2.3 2.1 1.7 (at 100% coverage) Cost per head of population at 100% coverage (US$) 0.03 0.03 0.11 0.24 Source: World Health Organization, CHOICE (database), http://www.who.int/choice/costs. 230 Mental, Neurological, and Substance Use Disorders vary considerably among countries, given their different assessed (figure 12.3). For a district with a total popula- epidemiological mental health profiles, national policies, tion of one million persons, therefore, an annual outlay and access to health care. of US$250,000–US$700,000 would be required to reach Analytical tools and methods for financial planning the specified target coverage levels. The outlier is South have been developed for many disease areas and pro- Africa, where the prevailing price and quantity of health grams; these have been used to estimate the cost of sig- care service inputs are much higher. The cost per capita nificantly scaling up the delivery of a specified package of delivering the specified care package at target coverage of mental health care in LMICs (Chisholm, Lund, and levels in the South African district approaches US$2.50 Saxena 2007). These authors carried out a financial anal- per capita; this is higher than in the other countries but ysis to estimate the expenditures needed to scale up over relatively low in the context of current health spending a 10-year period the delivery of a specified mental health levels in South Africa. care package, comprising pharmacological and/or psy- Getting to target levels of annual spending in each chosocial treatment for schizophrenia, bipolar disorder, district would necessitate a steady budgetary increase, depression, and hazardous alcohol use. Current service estimated at US$0.02–US$0.11 extra per head of popu- levels in 12 selected LMICs were established using the lation per year if a 10-year period is used. Extending the WHO-AIMS (Assessment Instrument for Mental Health cost estimation to take into account program manage- Systems) assessment tool. ment and some utilization of specialist, hospital-based The analysis estimated the costs to meet the specified services by the district population increases these base- target coverage levels of 80 percent of cases with psy- line cost projections, substantially so in India and South chosis and bipolar disorder, and 25–33 percent of cases Africa (by at least 100 percent) and modestly so in the with depression and risky drinking. Spending for this other three sites (by approximately 20 percent). These package would need to be approximately US$2.00 per upper cost estimates amount to only 1 percent of total capita in LICs (compared with current spending of current health spending per capita in South Africa and US$0.10–US$0.20), and US$3.00–US$4.00 in middle- up to 7 percent in Ethiopia. income countries. For a middle-income country of A limitation of the costing methods used for this 50 million people, total annual spending on the pack- recent analysis is that they are unable to take proper age would amount to between US$150 million and account of critical health system constraints to service US$200 million. A subsequent, updated assessment of scale-up, such as midterm expenditure caps, supply-side the comparative cost-effectiveness analysis of 44 neurop- bottlenecks in recruiting staff or accessing essential sychiatric interventions in two WHO subregions (one in medicines, and inadequate referral and supervision Sub-Saharan Africa, the other in South Asia) estimated mechanisms. Such constraints can substantially alter the that the annual cost of delivering a defined package of actual level of program implementation or achievement. interventions for schizophrenia, depression, epilepsy, and Even if such supply-side factors were managed success- alcohol use disorders would be US$3–US$4 per capita fully, there is the additional concern that demand for (Chisholm and Saxena 2012). and actual uptake of available services do not match the This approach to service costing has been applied desired levels of effective coverage, for example because more recently to the subnational context of scaling of the influence on help-seeking behaviors of stigma up mental health services in LMICs, as part of the around mental illness. Broader environmental and polit- PRogramme for Improving Mental health carE (PRIME) ical factors can likewise impact the success or efficiency study being conducted at the district level in Ethiopia, of implemented strategies of care or prevention. India, Nepal, South Africa, and Uganda (Lund and oth- ers 2012). The costing analysis was carried out to inform CONCLUSIONS local PRIME country teams about the expected resource implications and financial feasibility associated with the This chapter reviewed the available evidence concerning implementation of their respective district mental health the cost and cost-effectiveness of interventions for the care plans (Chisholm, Burman-Roy, and others 2015). protection, prevention, and treatment of MNS disor- The results indicated that, starting from a generally very ders. The review has shown that there is a considerably low base of mental health service coverage and expen- greater economic evidence base now than there was diture, the cost of scaled-up provision in nonspecialist when Disease Control Priorities in Developing Countries, health care settings of an evidence-based package of first edition, was published (Jamison and others 1993). care that included psychosis, depression, alcohol use Seminal clinical trials of the treatment of common men- disorders and, in some countries, epilepsy, range from tal disorders in LMICs have included a cost-effectiveness US$0.25 to US$0.70 per capita in four of the five districts component. Country- and regional-level economic Cost-Effectiveness and Affordability of Interventions, Policies, and Platforms 231 Figure 12.3 Costs of Scaling Up a Mental Health Care Package in Nonspecialized Health Care Settings in Five Low- and Middle-Income Country Districts 2.50 Cost per head of population (2012 US$) 2.00 1.50 1.00 0.50 0 Current Target Current Target Current Target Current Target Current Target Sodo district Sehore district Chitwan district Kenneth Kaunda Kamuli district (Ethiopia) (India) (Nepal) district (Uganda) (South Africa) Alcohol use disorders $0.006 $0.052 $0.023 $0.057 $0.002 $0.035 $0.061 $0.477 $0.003 $0.054 Epilepsy $0.036 $0.210 $0 $0 $0.028 $0.136 $0 $0 $0.062 $0.184 Psychosis $0.017 $0.144 $0.030 $0.098 $0.007 $0.317 $1.081 $1.505 $0.011 $0.072 Depression $0.024 $0.155 $0.014 $0.097 $0.006 $0.178 $0.284 $0.530 $0.007 $0.073 Source: Chisholm, Burman-Roy, and others 2015. modeling studies have been conducted for a range Africa, the other in South-East Asia). This wide range of of disorders, permitting comparison of relative cost- cost-effectiveness points to the importance of carefully effectiveness with other DCPs. Arguably, there is now evaluating and choosing an appropriate set of inter- sufficient evidence to counteract or debunk the overgen- ventions for scaled-up investment and implementation; eralized claim that treatment of mental disorders is not a selecting an inefficient set will waste money and limit cost-effective use of scarce health care resources. potential health gains. Unfortunately, however, a high As with any other area of health, the reality is that proportion of mental health budgets is being used in the the range of possible interventions varies a great deal provision of the least cost-effective interventions, such with respect to their cost-effectiveness. An analysis of as long-term inpatient treatment of severe mental dis- 500 single and combined interventions assessed by the orders in mental hospitals. Very little is invested in more WHO-CHOICE project for the prevention and control cost-effective strategies, including the community-based of noncommunicable diseases and injuries in two LMIC provision of adjuvant psychosocial treatment for severe regions found that costs differed by at least three orders mental disorders, and measures to reduce access to or of magnitude (from a few cents to more than US$10 per marketing of alcohol. capita), as did cost-effectiveness (from US$10 to more Ultimately, policies are enacted and resources than US$100,000 per healthy life year gained) (Chisholm allocated at the level of individual countries. It is and others 2012). important that more economic evidence be generated In the economic analysis for MNS disorders in this alongside clinical trials or other evaluations at the series, Chisholm and Saxena (2012) found a very sub- national level, rather than relying on international stantial range of cost-effectiveness, with alcohol control estimates that may lack sensitivity to local priorities measures, drug treatment for epilepsy, and depression or health system characteristics. Our review high- treatment identified as offering the best value for money lighted several cost-effectiveness studies from high in the two WHO subregions assessed (one in Sub-Saharan as well as lower-income country settings to show 232 Mental, Neurological, and Substance Use Disorders the informational and policy value of such evalua- World Bank Income Classifications as of July 2014 are as tions. 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Health 8: 20. 236 Mental, Neurological, and Substance Use Disorders Chapter 13 Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis Dan Chisholm, Kjell Arne Johansson, Neha Raykar, Itamar Megiddo, Aditi Nigam, Kirsten Bjerkreim Strand, Abigail Colson, Abebaw Fekadu, and Stéphane Verguet INTRODUCTION represent other important goals; a well-functioning health system should deliver high-quality services to all Universal Health Coverage and Mental, Neurological, people, whenever and wherever they need those services and Substance Use Disorders (WHO 2010a). A health system functions fully only if it Health System Goals protects the right to health for everyone, including peo- Health systems are complex entities, involving the devel- ple with MNS disorders. That right to health includes opment of appropriate policies and legal frameworks, physical or geographical access to essential services, as mobilization and allocation of resources, organization, well as financial access, so that those in need can use and and actual delivery of services, as well as the timely benefit from services without risking financial hardship. evaluation of these components. Ultimately, the goal of such a system and each of its parts is to improve the Toward Universal Health Coverage for Mental, mental and physical health of the population it seeks Neurological, and Substance Use Disorders to serve, revealed in terms of enhanced well-being or MNS disorders pose several service and financial access declining rates of morbidity and mortality. challenges. First, persons with these disorders are too Earlier chapters in this volume showed the extent of often subjected to discrimination and stigmatization, global health losses associated with a range of mental, which can reduce their willingness to seek care. Second, neurological, and substance use (MNS) disorders— individuals may be unaware of their condition and and how the implementation of evidence-based, not seek or know about appropriate treatment. Third, cost-effective treatment and prevention strategies can MNS disorders are typically chronic and require ongo- mitigate these losses. This chapter goes further by ing treatment. Yet health care and treatment for MNS considering important attributes of health systems disorders are often excluded from essential packages other than health improvement itself, namely, equity of care or insurance schemes. Without such coverage, and financial protection. Equitable access to care, fair people with MNS disorders and their families face a financing, service quality, and human rights protection difficult choice: pay out-of-pocket (OOP) for treatment Corresponding author: Dan Chisholm, Department of Health System Financing, World Health Organization; chisholmd@who.int. 237 by private providers of variable and sometimes poor of MNS disorders in two distinct geographical and quality—often by cutting other household spending and health system contexts: India and Ethiopia. India is a investment, or by liquidating assets or savings—or go very large, lower-middle-income country in South Asia; without treatment altogether. Ethiopia is a large, low-income country in East Africa. Either way, MNS disorders pose a direct threat to We selected these two countries for in-depth analysis the well-being of households. In India, for example, because both have recently articulated ambitious plans the National Sample Survey Organization found that to enhance mental health service quality and coverage, in 2004, national OOP expenditures for treatment of as well as to extend financial protection or health insur- psychiatric disorders amounted to nearly Rs 7 billion ance for their citizens. (US$280 million in 2012 US$), half of which was bor- rowed, and a further 40 percent drawn from household income or savings (Mahal, Karan, and Engelgau 2010). Extended Cost-Effectiveness Analysis: Principles Another study, conducted in the Indian state of Goa, and Practice found that 15 percent of women with common mental Objectives and Components disorders, such as depression or anxiety, spent more than In addition to health gains, a potential nonhealth ben- 10 percent of household income on health-related care efit of specific interventions or policies, such as public (Patel and others 2007). financing, is the value that some form of health insur- The high, potentially catastrophic cost to households ance bestows on households that would otherwise pay of securing needed health services and goods is a funda- privately for health services and goods. Because OOP mental concern underlying the drive toward universal spending for the care and treatment of MNS disorders health coverage (UHC). Direct OOP payments represent can be considerable and enduring, the reduction or a regressive form of health financing—penalizing those elimination of such expenditures can represent major least able to afford care—and are an obvious channel savings or even financial salvation for affected house- through which impoverishment may occur or deepen. holds. Public financing of health service costs can also Prepayment mechanisms, such as national or social increase the use of services, especially for those whose insurance, more equitably safeguard at-risk populations incomes are so low that they do not access services in from the adverse financial consequences of mental disor- the first place. ders. Accordingly, ongoing efforts to move toward UHC Our application of ECEA to MNS disorders focuses focus on increasing (1) the proportion of the population on public financing as an instrument for financial risk covered by some form of financial protection; (2) the protection (FRP). Public financing provides FRP ben- proportion of total costs covered by some form of pre- efits to households by shielding them from the OOP payment, such as health insurance; and (3) the depth of costs and impoverishment-related consequences of the coverage (the range of services or interventions available covered health care services (Verguet and others 2015). to insured persons) (WHO 2010a). Our approach to the measurement of FRP is described Current coverage of essential health care and treat- in box 13.1. ment services for MNS disorders is limited, in terms Another essential component of ECEA is its examina- of access and financial protection or benefit inclusion. tion of the distribution of health and economic benefits Efforts to scale up community-based public health by population subgroup, for example, by geographical services for these conditions can contribute strongly to location, care setting, or income quintile. Such an anal- greater equality of access, because such services will serve ysis enables policy makers to understand how an inter- more people in need, with less reliance on direct OOP vention or a policy such as public financing would affect spending. This chapter explores the veracity of this claim different segments of the population, particularly those through an innovative approach to economic evalua- with low incomes or high vulnerability. tion called extended cost-effectiveness analysis (ECEA) In short, ECEA provides a tool to amplify under- (Verguet, Laxminarayan, and Jamison 2015; Verguet and standing of the extent and distribution of health others 2015). and financial benefits associated with health policies ECEA goes beyond conventional cost-effectiveness and interventions. Elucidation and enumeration of analysis (CEA) not only by considering the distribution these benefits provides a more holistic assessment of of costs and outcomes across different socioeconomic the expected returns on health service investments groups in the population, but also by explicitly examin- while providing new, evidence-based insights to the ing the extent to which interventions or policies protect national policy makers responsible for setting prior- households against the financial risk of medical impov- ities and allocating resources within and beyond the erishment. We apply this ECEA approach to a range health sector. 238 Mental, Neurological, and Substance Use Disorders Box 13.1 Measuring the Financial Risk Protection Effects of Health Policies Several metrics can be used to quantify the finan- To estimate the FRP, we first estimated the individu- cial risk protection (FRP) benefits of health pol- al’s expected income before public financing, which icies. One approach is to estimate the amount of depends on treatment coverage and associated OOP households’ private out-of-pocket (OOP) expen- costs. We then estimated the individual’s certainty ditures averted by the policy; another is to esti- equivalent by assigning individuals a utility function mate the number of cases of poverty averted by that specifies their risk aversion, which is equivalent counting the number of individuals no longer to calculating their willingness to pay for insurance falling under a poverty line/threshold because against the risk of medical expenditures. Finally, we of substantial OOP medical expenditures. In derived a money-metric value of the insurance pro- this study, we used as FRP metric the money- vided by public financing (risk premium) as the dif- metric value of insurance provided by public ference between the expected value of income and the financing (Verguet, Laxminarayan, and Jamison certainty equivalent (Verguet, Laxminarayan, and 2015), which quantifies insurance risk premiums; Jamison 2015). Aggregating the money-metric value it reflects risk aversion, in which individuals of insurance with the income distribution of the would prefer the certainty of insurance over the population—with a proxy based on the country’s uncertainty/risk of possible OOP expenditures, gross domestic product per capita and Gini and hence are willing to pay a certain amount of coefficient—yielded a dollar value of FRP at the soci- money to avoid that risk. etal level. Application to Mental, Neurological, and Substance health worker care package, and the prevention of com- Use Disorders mon mental disorders and substance use disorders as ECEA is applicable to many interventions to prevent part of a school-based intervention package. or treat MNS disorders, whether considered separately These analyses focus on establishing the distribu- or in combination. However, since this approach to tional consequences and the value of FRP resulting economic analysis is new and yet to be tried in the from increased levels of publicly financed interventions. context of MNS disorders, our first goal was to test its Because the availability and use of mental health services applicability and assess its internal validity. We accom- in most low- and middle-income countries is very low, plished this by constructing a series of equation-based however, the economic benefit associated with a switch ECEA models that employed the same epidemio- from private to public payment for services would logical and treatment cost-outcome input data used be correspondingly small. Accordingly, we assess the in previous CEA studies, such as the treatment of impacts of increased FRP and increased service coverage. psychosis, bipolar disorder, and depression with psy- chosocial treatment and psychotropic medication, which Chisholm and Saxena (2012) already examined TOWARD UNIVERSAL HEALTH COVERAGE: in the contexts of Sub-Saharan Africa and South-East Asia. Additional information output from the ECEA TWO COUNTRY ANALYSES model—particularly the estimated value of FRP aris- Although analysis has only been conducted for the ing from public financing of health care costs—could two countries presented, the insights and lessons then be readily interpreted with reference to this ear- from it have a far broader applicability that can be lier published work. confirmed through further country-based work using We combined the results of these intervention-specific the methods and models developed for this chapter. analyses to evaluate the impact of defined packages of Analysis of this kind can be of particular informa- care. Future applications of the ECEA approach could tional value to other countries planning to reform focus more on prevention, including the prevention of their mental health programming and public health childhood behavioral disorders as part of a community financing policies. Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis 239 India make several simplifying assumptions so that the results India’s health sector is undergoing a rapid and stark are comparable to the ECEAs presented for schizophre- transition, not only in epidemiological terms as the nia and depression treatment. For example, treatment- deaths and disabilities from chronic diseases and injuries seeking costs, such as travel expenses, were omitted. The take an ever-higher toll, but also in systemic terms as analysis by Megiddo and others (2016) also employs efforts to improve service quality and expand financial differing government and consumer costs, but here we protection take effect (Patel and others 2011). In par- assume the costs of a given service to be equal, regardless ticular, there is a strong push to move toward universal of the purchaser. public finance (UPF)—the government finances an Prevalence and other epidemiological parameters intervention irrespective of who is delivering or receiv- came from the Global Burden of Disease (GBD) 2010 ing it—to reverse decades of high, often impoverishing study estimates for South Asia (Whiteford and others OOP health care expenditures and to allocate resources 2013). For calculation of healthy life-years, we applied more equitably. the following disability weights: 0.072 for seizure-free This subsection estimates the expected health and patients, 0.319 for patients with seizures, and 0.420 for economic benefits of scaling up services for the treat- untreated individuals with epilepsy (IHME 2012). For ment of three prominent contributors to the burden of each scenario, we estimated the policy’s impact on pop- MNS disorders: epilepsy, schizophrenia, and depression. ulation health (healthy life-years gained), direct govern- All monetary values are expressed in 2012 US$. ment expenditures, OOP expenditures averted, and the FRP provided. Enhanced Financial and Service Coverage of Epilepsy The results, presented in table 13.1, relate to a popu- Treatment lation of one million persons in the general population, Fewer than half of the estimated 6 million to 10 million divided into equal household income quintiles of 200,000 individuals with epilepsy in India receive any treatment persons. The model is dynamic, and the values change (Meyer and others 2010). To counter this health and over time (meaning that the data for each point in time financial burden, the Ministry of Health is considering a are needed to replicate the results exactly): here we pre- national epilepsy program that could increase access to, sent the results for the average year. The estimated disease and utilization of, treatment through three interventions burden associated with epilepsy amounts to 2,200 lost (Tripathi and others 2012): public awareness campaigns, years of healthy life per one million population. Current better training of health workers, and UPF for first- and intervention efforts lead to 503 healthy life-years gained second-line anti-epilepsy drugs (AEDs) and epilepsy (23 percent of the total estimated disease burden); the surgery. The ECEA that follows examines UPF—a policy three enhanced-coverage intervention scenarios result intervention that would also address the financial risk in gains of between 1,118 and 1,251 healthy life-years, posed by OOP spending on epilepsy treatment. The equivalent to more than 50 percent of the measured incremental impacts of three UPF interventions were disease burden. Public financing of second-line AEDs assessed: UPF for first-line AEDs (intervention 1); UPF as well as first-line AEDs to 80 percent of those in for first- and second-line AEDs (intervention 2); and need (intervention 2) generates 90 more healthy life- UPF for first- and second-line AEDs and epilepsy sur- years than intervention 1 alone; the addition of surgery gery (intervention 3). (intervention 3) adds a further 44 healthy life-years per First-line AEDs include carbamazepine, phenytoin, and one million population. Intervention health benefits are valproate, as well as phenobarbital; the second-line AED distributed equitably across income quintiles. is lamotrigine. Seventy percent of patients are expected The total cost of implementing intervention 1 is to respond to first-line AEDs; the remaining 30 percent US$0.16 per capita, rising to US$0.30 for intervention are allocated equally to three groups: those receiving 3 (table 13.1). Compared with no intervention, the cost second-line AED treatment, those receiving surgery, and per healthy life-year gained for all three intervention refractory cases who do not respond to any treatment. scenarios falls below US$200 (range: US$112–US$181). Each intervention increases access to the treatment Relative to the current situation, the incremental cost- provided by UPF to 80 percent (from less than 50 percent effectiveness of intervention 1 is US$70 per healthy life- without UPF). We estimate that 70 percent of all treat- year gained; intervention 3 is the next most cost-effective ment costs—including outpatient visits, inpatient visits, (incremental cost-effectiveness ratio US$850). and drugs—are paid OOP in the baseline and that the UPF coverage would avert more than US$100,000 interventions reduce OOP expenditures for the covered in OOP expenditures per one million population services to zero. Relative to the full model and detailed under intervention 1, and US$190,000 and US$208,000 results presented by Megiddo and others (2016), we under interventions 2 and 3, respectively. Finally, the 240 Mental, Neurological, and Substance Use Disorders Table 13.1 Extended Cost-Effectiveness Analysis of Publicly Financed Epilepsy Treatment in India Income quintile Total (per one million Outcome I II III IV V persons) a Averted disease burden Current burden (healthy life-years lost) 448 440 442 432 435 2,197 Current-coverage averted burden (healthy life-years gained) 89 95 99 112 108 503 Intervention 1 averted burden (healthy life-years gained) 221 219 224 229 225 1,118 Intervention 2 averted burden (healthy life-years gained) 238 237 242 245 245 1,207 Intervention 3 averted burden (healthy life-years gained) 248 247 250 254 252 1,251 b Cost of care ($) Current-coverage total costs 19,738 21,120 21,167 23,393 22,864 108,283 Current-coverage private expenditures averted (under UPF) 13,817 14,784 14,817 16,375 16,005 75,798 Intervention 1 total costs 32,930 33,132 33,431 33,536 33,608 166,636 Intervention 1 private expenditures averted (under UPF) 23,051 23,192 23,401 23,475 23,526 116,645 Intervention 2 total costs 53,830 53,893 54,578 54,757 54,976 272,033 Intervention 2 private expenditures averted (under UPF) 37,681 37,725 38,204 38,330 38,483 190,423 Intervention 3 total costs 58,980 59,121 59,421 59,810 59,381 296,714 Intervention 3 private expenditures averted (under UPF) 41,286 41,385 41,595 41,867 41,567 207,699 c Insurance value ($) Intervention 1 778 484 408 253 176 2,098 Intervention 2 4,096 2,699 1,925 1,490 899 11,109 Intervention 3 4,096 2,699 1,925 1,490 1,200 11,410 Source: Megiddo and others 2016. Note: UPF = universal public financing for 80 percent of the population in need. Intervention 1 = UPF for first-line anti-epileptic drugs (AEDs). Intervention 2 = UPF for first- and second-line AEDs. Intervention 3 = UPF for first- and second-line AEDs and epilepsy surgery. First-line AEDs include carbamazepine, phenytoin, and valproate, as well as phenobarbital. The second-line AED is lamotrigine. Results are based on a population of one million people, with intervention benefits equally divided among income quintiles of 200,000 persons each (quintile I having the lowest household income and quintile V the highest). All monetary values are expressed in 2012 US$. a. The estimated disease burden, expressed as healthy life-years lost or gained, is drawn from the Global Burden of Disease 2010 study for South Asia (Whiteford and others 2013). Healthy life-years lost are based on the prevalence of individuals with active epilepsy: seizure-free patients (disability weight [DW] 0.072), patients with seizures (DW 0.319), and untreated individuals with seizures (DW 0.420). b. Total costs = (direct government expenditures) + (private expenditures, including out-of-pocket costs). The costs and expenditures are based on the number of prescriptions and surgeries, which are dependent on the prevalence of epilepsy and the coverage of treatment. c. Insurance value = financial risk protection provided, based on current coverage. monetized value of insurance was found to amount to Enhanced Financial and Service Coverage of US$11,000 per one million population for interventions Schizophrenia Treatment 2 and 3, with evidence of a clear trend for it to decrease Schizophrenia poses a considerable public health with wealth. For example, the poorest quintile derives and social policy challenge because of its severity, its 37 percent of the total insurance value, compared with often catastrophic effect on the welfare and income of 8 percent for the wealthiest. family members, and the significant risk that patients The primary conclusion from this analysis is that will suffer severe human rights violations. Here we intervention 1 is the most cost-effective and least costly analyze the impact of enhanced public financing and strategy to implement from a public payer perspec- provision of schizophrenia treatment on health and tive, but intervention 3—increased service and finan- financial outcomes, including increased uptake of cial coverage of first- and second-line AEDs, as well as treatment (leading to more health gains), reduced surgery—would generate the greatest level of health gain OOP treatment costs, and greater insurance against and offer the greatest level of financial protection at the catastrophic health expenses (Raykar, Nigam, and population level. Chisholm 2015). Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis 241 In this model, all persons treated for schizophrenia 30 percent in the poorest income group to 50 percent in nonspecialized health care settings receive a combi- in the richest). Target coverage for all income groups nation of first-generation antipsychotic drugs, such as was set at 80 percent, meaning that 80 percent of those haloperidol or chlorpromazine, as well as basic—or, for needing treatment would receive publicly financed care. a small proportion, intensive—psychosocial treatment. Schizophrenia prevalence rates for South Asia were Fifteen percent of cases are expected to require short- taken from the GBD 2010 study (Whiteford and others term inpatient psychiatric care; 2 percent are assumed to 2013), stratified by region, age, and gender, but not by be long-term residential patients in community-based income. To derive prevalence rates by income group, facilities; and 50 percent receive hospital outpatient care these estimates were applied to the household survey in (Chisholm and others 2008). India (District Level Household and Facility Survey-3); The resulting cost per treated case is US$177 per this showed a higher prevalence among higher-income year. Given that OOP spending as a share of total health groups, which could reflect better detection, greater expenditure amounts to at least 70 percent for noncom- health service uptake, or both. Disability weights, which municable diseases in India (Mahal, Karan, and Engelgau are necessary for the calculation of healthy life-years lost 2010), we estimate that the annual expected cost to or gained, are 0.576 and 0.756 for residual and acute households would be US$124. Treatment improves the cases, respectively (IHME 2012). A composite disability average level of functioning or disability by an estimated weight of 0.612 was used, based on a weighted average of 24 percent (Chisholm and others 2008); adherence to acute (20 percent) and residual (80 percent) cases. treatment was set at 76 percent (Chatterjee and others The results, displayed in table 13.2, indicate that the 2014). The estimated proportion of total cases currently current public health burden of schizophrenia amounts receiving treatment in India is 40 percent (Murthy to 1,700 lost healthy life-years per one million popula- 2011), to which we applied a socioeconomic gradient tion. Treatment of schizophrenia with a combination to account for increased detection and health care uti- of psychosocial treatment and antipsychotic medica- lization rates among wealthier groups (ranging from tion generates 126 healthy life-years at current levels of Table 13.2 Extended Cost-Effectiveness Analysis of Publicly Financed Schizophrenia Treatment in India Income quintile Total (per one Outcome I II III IV V million persons) Averted disease burdena Current burden (healthy life-years lost) 307 316 333 354 394 1,704 Current-coverage averted burden (healthy life-years 17 20 24 29 36 126 gained) Target-coverage averted burden (healthy life-years 45 46 49 52 57 249 gained) Cost of care ($)b Current-coverage total costs 26,721 32,042 38,666 46,156 57,059 200,644 Current-coverage private expenditures averted 18,705 22,429 27,066 32,309 39,942 140,451 (under UPF) Target-coverage total costs 71,257 73,238 77,331 82,055 91,295 395,176 Target-coverage private expenditures averted 49,880 51,267 54,132 57,439 63,906 276,623 (under UPF) Insurance value ($)c 7,282 5,587 4,972 4,302 2,439 24,582 Source: Raykar, Nigam, and Chisholm 2015. Note: UPF = universal public financing for 80 percent of the population in need. Results are based on a population of one million people, with intervention benefits equally divided among income quintiles of 200,000 persons each (quintile I having the lowest household income and quintile V the highest). Target coverage of UPF for schizophrenia treatment for all income groups was set at 80 percent. All monetary values are expressed in 2012 US$. a. The estimated disease burden, expressed as healthy life-years lost or gained, is drawn from the Global Burden of Disease 2010 study for South Asia (Whiteford and others 2013). b. Total costs = (direct government expenditures) + (private expenditures, including out-of-pocket costs). c. Insurance value = financial risk protection provided, based on current coverage. 242 Mental, Neurological, and Substance Use Disorders coverage in the population, and 249 at target coverage of the total insurance value (estimated at US$24,582) rates, equivalent to 7.4 percent and 14.6 percent of the is bestowed on the poorest quintile of the population, current disease burden, respectively (Raykar, Nigam, and compared with 10 percent for the richest quintile. Chisholm 2015). Each healthy life-year would be gained at a cost of approximately US$1,600. Enhanced Financial and Service Coverage of Public financing of the 70 percent of treatment costs Depression Treatment incurred by households would remove US$140,000 of As the single-largest contributor to the burden of men- OOP spending per one million population at current tal and behavioral disorders, depression presents major coverage, and US$277,000 at target coverage (US$0.28 public health and economic challenges to India. Using per capita). On top of the share already financed publicly the same methods and data sources as those applied to (30 percent), this would take the total government cost schizophrenia, we assess the consequences of scaled-up to US$0.39 per capita. The health impacts of healthy life- service and financial coverage for depression. years gained and averted OOP spending would be higher In this model, all cases of depression receive basic for higher-income groups; however, UPF would still psychosocial treatment, advice, and follow-up in non- flatten the distribution of public health spending appre- specialized health care settings; 20 percent receive more ciably away from today’s regressive pattern to a more intensive psychological treatment (an average of eight equitable allocation of resources, as shown in figure 13.1 sessions); and 70 percent are prescribed a generic selec- and Mahal, Karan, and Engelgau (2010). Moreover, anal- tive serotonin reuptake inhibitor (SSRI) antidepressant ysis of the insurance value indicates that increasing ser- (fluoxetine). Hospital-based outpatient and inpatient vice and financial coverage for schizophrenia treatment services are used by 20 and 2 percent of cases, respec- in India would have a clear pro-poor effect: 30 percent tively. The mean cost per treated episode is estimated to Figure 13.1 Distribution of Public Spending and Insurance Value of UPF for Schizophrenia Treatment in India, by Income Quintile a. Distribution of public spendinga b. Distribution of UPF insurance valueb 30 8,000 7,000 25 6,000 Public health spending (%) Value of insurance ($) 20 5,000 15 4,000 3,000 10 2,000 5 1,000 0 0 I II III IV V I II III IV V Income quintile Income quintile Current distribution (without UPF) Revised distribution (with UPF) Source: Raykar, Nigam, and Chisholm 2015. Note: UPF = universal public finance. Results are based on a population of one million people, with intervention benefits equally divided among income quintiles of 200,000 persons each (quintile I having the lowest household income and quintile V the highest). All monetary values are expressed in 2012 US$. a. Target coverage of UPF for schizophrenia treatment for all income groups was set at 80 percent. Current coverage ranges from 30 percent in the poorest income group to 50 percent in the richest. This panel shows the distribution of public health spending across income quintiles before and after the introduction of UPF. b. Insurance value is the financial risk protection provided by UPF for those in contact with services. This panel shows the distribution of final protection benefits across income quintiles resulting from a policy of UPF; the value of insurance is per income quintile (each with 200,000 persons). Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis 243 be close to US$35 (Chisholm and Saxena 2012; Patel and coverage, which is skewed in favor of the richer quintiles. others 2011), of which 70 percent (US$25) is projected The total cost of providing this elevated level of service to be paid by households. Treatment affects the dura- coverage approaches US$700,000 per one million pop- tion of a depressive episode and is expressed here as an ulation per year, or US$0.70 per head of population, improvement in the remission rate by 35 percent, sub- compared with US$0.28 now. Publicly financing this sequently adjusted downward to reflect expected rates scaled-up treatment will avert more than US$477,000 of nonadherence of 70 percent (Chisholm and Saxena of OOP spending per one million population, shared 2012). We modeled the impact of moving from current fairly equally among income quintiles. The overall coverage (ranging from an estimated 10 percent for the insurance value is approximately US$5,400, much lower lowest-income quintile to 30 percent for the highest) to than that of schizophrenia treatment because of the a target coverage of 50 percent for all income groups. lower coverage rate and cost of treatment, and also As shown in table 13.3, the public health burden of much flatter (there is no clear income gradient between depression is considerable (more than 14,000 healthy quintiles I–IV). life-years lost per one million population). At current coverage rates in the population, treatment is estimated Combination Package to generate 729 healthy life-years (equivalent to only Combining the results of these analyses of UPF for the 5 percent of current disease burden) per million pop- treatment of epilepsy, schizophrenia, and depression, ulation. With coverage scaled up to 50 percent, close to several findings become apparent. First, over 90 percent 1,800 healthy life-years would be gained, equivalent to of the total avertable burden of disease, in healthy life- 12 percent of the current disease burden; as a proportion years gained per one million population, is attributable of current burden, the impact is similar to that of schizo- to UPF of treatment for depression and epilepsy; UPF of phrenia treatment, but because of the higher prevalence treatment for schizophrenia accounts for only 7 percent of depression, the absolute amount of avertable health of the 3,683 healthy life-years. Second, UPF for treat- gain in the population is at least five times greater. ment of depression also accounts for the greatest share As in the case of schizophrenia treatment, health ben- of averted OOP spending at specified target-coverage efits are distributed much more evenly across income levels—half in this instance (US$477,000 of a total of groups at the assumed scaled-up coverage level of US$962,000 per one million population). Both of these 50 percent among all income groups than under current findings reflect the larger number of prevalent cases Table 13.3 Extended Cost-Effectiveness Analysis of Publicly Financed Depression Treatment in India Income quintile Total (per one million Outcome I II III IV V persons) a Averted disease burden Current-coverage burden (healthy life-years lost) 2,754 2,817 2,914 2,996 3,153 14,633 Current-coverage averted burden (healthy life-years gained) 67 104 143 184 232 729 Target-coverage averted burden (healthy life-years gained) 337 345 357 367 386 1,793 Cost of care ($) b Current-coverage total costs 25,669 39,385 54,318 69,821 88,178 277,371 Current-coverage private expenditures averted (under UPF) 17,968 27,569 38,023 48,875 61,725 194,160 Target-coverage total costs 128,346 131,282 135,795 139,642 146,964 682,028 Target-coverage private expenditures averted (under UPF) 89,842 91,897 95,056 97,750 102,875 477,420 c Insurance value ($) 1,101 1,167 1,232 1,183 717 5,400 Note: UPF = universal public financing for 50 percent of the population in need. Results are based on a population of one million people, with intervention benefits equally divided among income quintiles of 200,000 persons each (quintile I having the lowest household income and quintile V the highest). Target coverage of UPF for depression treatment for all income groups was set at 80 percent. All monetary values are expressed in 2012 US$. a. The estimated disease burden, expressed as healthy life-years lost or gained, is drawn from the Global Burden of Disease 2010 study for South Asia (Whiteford and others 2013). b. Total costs = (direct government expenditures) + (private expenditures, including out-of-pocket costs). c. Insurance value = financial risk protection provided, based on current coverage. 244 Mental, Neurological, and Substance Use Disorders in the population. By contrast, by far the largest share importance of an efficient, equitable scale-up of mental of the composite value of insurance is associated with health care within a broader, ongoing effort to increase UPF of schizophrenia treatment (77 percent of the total levels of health insurance in the general population US$32,000 per one million population). (Federal Democratic Republic of Ethiopia 2010). Comparing these results by income quintile rather This section on the ECEA of UHC for MNS disorders than by disease shows that, at target coverage levels, assesses the health, distributional, and financial impacts the averted disease burden and averted OOP expen- of scaling up a publicly financed mental health program ditures are shared more or less equally across income in Ethiopia. Unlike the Indian analysis, which considered groups (not shown). However, the value of insurance each disease in turn before assessing the combined effect, is markedly skewed toward the poorer income groups the primary interest here was in the cumulative impact (figure 13.2). of a defined package of care. In addition, this Ethiopian analysis includes an assessment of the potential produc- tivity effects of scaling up for depression. Ethiopia Ethiopia is one of many low-income countries in Sub- Enhanced Financial and Service Coverage of a Mental Saharan Africa that is facing a severe shortage of skilled and Neurological Health Care Package workers and other resources for addressing the burden The basic scale-up scenario in the National Mental Health of MNS disorders; for example, there are only 0.4 psy- Strategy targets treatment for depression, schizophrenia, chiatrists per one million population in Ethiopia, com- bipolar disorder, and epilepsy—all of which are priority pared with a global average of more than 10. However, disorders in the World Health Organization’s (WHO) the Ethiopian government has launched a National Mental Health Gap Action Programme (mhGAP) Mental Health Strategy to scale up mental health services Intervention Guide (WHO 2010b). We included for this over the next decade (Federal Democratic Republic of analysis the most cost-effective interventions for each dis- Ethiopia 2012). The strategy explicitly recognizes the ease category, identified through a recent contextualized Figure 13.2 Composite Value of Insurance through UPF for Treatment of MNS Disorders in India, by Illness and Income Quintile 10,000 9,000 Value of insurance per 1 million 8,000 population (2012 US$) 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 I II III IV V Epilepsy 778 484 408 253 176 Depression 1,101 1,167 1,232 1,183 717 Schizophrenia 7,282 5,587 4,972 4,302 2,439 Income quintile Note: MNS = mental, neurological, and substance use; UPF = universal public finance. Value of insurance = financial risk protection provided at current coverage. Results are based on a population of one million people, equally divided into income quintiles of 200,000 persons each (quintile I having the lowest household income and quintile V the highest). Results assume target coverage levels of 80 percent for all income groups. Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis 245 CEA of the National Mental Health Strategy (Bjerkreim depression and epilepsy. The costs and health benefits Strand and others 2015). The selected interventions of the intervention package are estimated to be higher include phenobarbital for epilepsy, fluoxetine combined for the lowest-income groups (table 13.4) based on with cognitive therapy and proactive case management the higher prevalence and treatment gap among those for depression, valproate combined with psychosocial groups. Similarly, the measured value of insurance therapy for bipolar affective disorder, and first-line anti- is highest among the lowest-income group. Although psychotic medication (haloperidol or chlorpromazine) UPF would reduce household private expenditures for plus psychosocial treatment for schizophrenia. those with current access to care, the averted OOP As with the Indian analyses, the ECEA splits the pop- expenditures would be extremely low, given the very low ulation into five income quintiles and runs the analyti- current access to and coverage of treatment services (less cal model for each income group with quintile-specific than 5 percent), particularly among the lower-income prevalence rates. The average age-specific disease preva- quintiles (Bjerkreim Strand and others 2015). In other lence rates used in the standard CEA (Bjerkreim Strand words, the FRP of UPF is extremely low because of the and others 2015) were distributed into income-quintile- low current level of private spending on mental health specific prevalence rates, using a population-based care in Ethiopia, a direct consequence of the very low prevalence study conducted in Ethiopia (n = 1,497) coverage of services. (Fekadu and others 2014).1 Disease-specific mortality, Findings from this ECEA indicate that investing intervention coverage, and intervention effectiveness in UPF of public mental health will create substantial were held constant in each income group. Estimates of health benefits, but it will most likely produce a low the efficacy of interventions were drawn from system- degree of FRP. Accordingly, while the ECEA approach atic reviews, meta-analyses, and randomized controlled captures FRP and equity in the economic evaluation of trials (full details can be found in Bjerkreim Strand and mental health policy, the FRP benefits are less relevant others 2015). when the current utilization and spending on care is Current treatment coverage for all disorders is less low, as they are in Ethiopia. Nevertheless, we expect that than 5 percent (Bjerkreim Strand and others 2015). many families experience impoverishing loss of income Following the introduction of UPF, and in line with the because of mental disorders. National Mental Health Strategy, coverage for all income groups is modeled to reach 75 percent for treatment of Productivity Impact of Scaled-Up Depression schizophrenia and epilepsy, 50 percent for treatment of Treatment bipolar disorder, and 30 percent for treatment of depres- Owing to low levels of current investment, OOP spend- sion (Federal Democratic Republic of Ethiopia 2012). ing averted and FRP conferred as a result of switching Target coverage for depression is lower than the other to a publicly financed model of mental health care disorders because of its higher prevalence and lower are modest. However, implementation of the National detectability. Mental Health Strategy can lead to other important wel- A significant proportion of total health spending in fare gains, in particular, productivity at the household Ethiopia is from OOP expenditures, varying between 30 and societal levels. and 40 percent of the total over the past 10 years (World Therefore, we also explored the expected productiv- Bank 2014). This analysis assumes a current household ity gains from scaling up the provision of depression contribution of 34 percent toward the cost of treatment; care and treatment. We focused only on depression the government covers the remaining 66 percent. To because the disease burden of depression is high, estimate the amount of household OOP expenditures and evidence indicates that depression has a substan- averted by UPF, we quantified what households would tial impact on productivity (Clark and others 2009; pay for illness-related treatment cost at current service Goetzel and others 2004). Between 1 and 3 percent of delivery levels. the adult Ethiopian population is estimated to have a For the country as a whole, which had a population of depressive episode at any given time, with an average 94.6 million in 2012 (United Nations 2015), the expected duration of 8.4 months (Bjerkreim Strand and others annual cost of implementing the defined mental and 2015). Productivity is lost during such episodes because neurological health care package at specified target cov- of increased absence from work (absenteeism) and erage levels is approximately US$153 million, equivalent decreased work performance when present at work to a little more than US$1.60 per capita (Johansson and (presenteeism). Depression treatment programs have others 2015). The return on this investment, in total been shown to improve rates of employment by up population health gain, exceeds 155,000 healthy life- to 5 percent in the United Kingdom (Clark and oth- years, the majority of which derives from treatment of ers 2009); in the United States, costs associated with 246 Mental, Neurological, and Substance Use Disorders Table 13.4 Extended Cost-Effectiveness Analysis of a Publicly Financed Mental and Neurological Health Care Package in Ethiopia Income quintile Total (per one million Outcome I II III IV V persons) a Healthy life-years gained (at target coverage) Schizophrenia 26 22 19 16 12 95 Bipolar disorder 58 50 43 35 28 214 Depression 173 152 130 108 86 649 Epilepsy 187 163 140 115 77 682 b Total cost of care (at target coverage) Schizophrenia ($) 75,900 66,100 56,300 46,400 36,600 281,200 Bipolar disorder ($) 109,300 95,100 81,000 66,800 52,600 404,800 Depression ($) 159,200 139,000 118,600 98,100 77,600 592,500 Epilepsy ($) 92,500 80,500 69,900 56,600 37,200 336,600 c Private expenditures averted (at current coverage) Schizophrenia ($) 380 330 280 230 180 1,420 Bipolar disorder ($) 1,140 990 840 700 550 4,220 Depression ($) 760 660 610 5870 470 2,840 Epilepsy ($) 2,610 2,280 1,980 1,600 1,600 9,520 Insurance value (at current coverage) d Schizophrenia ($) 0.08 0.03 0.01 0.01 0.01 0.14 Bipolar disorder ($) 3.2 1.1 0.6 0.6 0.3 5.7 Depression ($) 9.5 3.4 1.9 1.8 0.8 17.3 Epilepsy ($) 70.7 22.9 13.0 11.9 3.6 122.1 Source: Johansson and others 2015. Note: Results are based on a population of one million people, equally divided into income quintiles of 200,000 persons (quintile I has the lowest household income and quintile V the highest). Target coverage associated with enhanced public financing for all income groups was set at 30 percent for depression treatment, 50 percent for bipolar disorder, and 75 percent for the other two disorders. All monetary values are expressed in 2012 US$. a. The estimated disease burden, expressed as healthy life-years gained, is drawn from the Global Burden of Disease 2010 study for Eastern Sub-Saharan Africa (Whiteford and others 2013). b. Total cost of care = direct government expenditure associated with public financing at target coverage. c. Private expenditures averted = out-of-pocket spending that is eliminated by switching to public financing. d. Insurance value = financial risk protection provided, based on current coverage. presenteeism have been estimated to be higher than the Disability days (per month) because of depression are costs of treatment (Goetzel and others 2004). estimated to be 2.9 in low-income settings (Alonso To estimate the productivity impact across income and others 2011). Hence, we assumed treatment would groups from scaling up treatment of depression in reduce the number of disability days by 8.7 days in total Ethiopia, we first adapted the Goetzel and others (2004) (2.9 days * 2.9 months). Subsequently, the population approach to presenteeism to the context of Ethiopia. We with depression, target coverage (30 percent), and aver- used epidemiological, demographic, efficacy, and cost age daily income (per wealth quintile in the productive data from the contextualized CEA of mental health care age groups [ages 15–60 years]) were multiplied by this in Ethiopia by Bjerkreim Strand and others (2015). It change in absenteeism (8.7 days) to derive an estimate was estimated that treatment led to an average reduction of the potential productivity gains in Ethiopia. In addi- in the duration of a depressive episode of 2.9 months tion, persons with depression have been found to have (8.4 months * efficacy of 0.35). Second, this reduction 3.7 days with partial disability per month in low-income in duration was converted to reduction in absenteeism. countries (Bruffaerts and others 2012). Partial disability Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis 247 means that on-the-job productivity is reduced because by income group, for example, provides an important of disease; it was estimated that patients with depression equity dimension that has so far been largely absent from had 1.2 full days lost per month because of presentee- conventional economic evaluation methods (including ism, based on the assumption that each partial day is the WHO’s CHOICE [CHOosing Interventions that are equivalent to one-third of a full lost day. Subsequently, Cost-Effective] project and earlier editions of Disease the associated productivity gain was estimated using the Control Priorities). Identification of the averted OOP same method as for absenteeism.2 spending associated with a move to UPF usefully com- The results shown in table 13.5 indicate that scaled-up plements other research related to UHC, such as estima- depression treatment at 30 percent coverage could lead tion of the costs of scaling up services. to total productivity gains of close to US$40 million We found ECEA to be a feasible approach and a use- per year. The largest benefits accrue to the wealthier ful addition to the methodological toolbox available to quintiles because of their higher average income level analysts, particularly since it can be incorporated into (Johansson and others 2015). Our estimates indicate existing cost-effectiveness modeling frameworks. The that the expected productivity gain from scaled-up treat- main additional data requirement is to be able to break ment of depression is likely to reduce the expected gov- down epidemiological and other key input parameters ernmental cost of the treatment program by 71 percent. by income group, the source of which would typically We acknowledge that it is problematic to apply a be nationally representative demographic and health high-income country method to an agrarian economy surveys. Static and more dynamic approaches to ECEA like Ethiopia to estimate productivity losses. Nevertheless, modeling have been developed and employed; for MNS calculations of productivity impact, based on presentee- disorders with long-term impacts, or for other inter- ism and absenteeism, are applied to illustrate how such ventions, a dynamic, agent-based approach to modeling information may be an important supplement to infor- can be used that requires more data as well as analytical mation on the expected FRP of mental health care in a expertise, but may be better able to capture socio- low-income context. Appropriate measures of presen- demographic changes and disease interactions over time. teeism and absenteeism need to be contextualized and Whichever approach is used, both are subject to found for each particular setting. More conceptual and the inherent uncertainty surrounding population-level empirical work on this issue is needed. projections of intervention costs, impacts, and con- sequences, consideration of which is contained in the primary analyses underlying the base case findings CONCLUSIONS AND RECOMMENDATIONS reported in this chapter (Johansson and others 2015; This chapter employed a novel approach to the eco- Megiddo and others 2016; Raykar, Nigam, and Chisholm nomic analysis of mental health care interventions, with 2015). These uncertainty analyses indicate that results a view to gaining insights into intervention or policy for FRP—as well as overall costs and health effects—are impacts other than health gain itself. Assessment of the sensitive to assumptions around target coverage rates to health and nonhealth impacts of scaled-up treatment be achieved in the population, the proportion of total Table 13.5 Productivity Impact of Scaled-Up Depression Treatment in Ethiopia Income quintile Total Cost/outcome I II III IV V population Government cost of depression treatment program ($, millions) −15.1 −13.2 −11.2 −9.3 −7.3 −56.1 a Productivity gain from scaled-up depression treatment ($, million) Caused by absenteeism 3.0 4.9 5.9 6.6 7.9 28.3 Caused by presenteeism 1.2 2.0 2.4 2.7 3.3 11.6 b Net societal cost of depression treatment program ($, million) −10.9 −6.3 −2.9 −0.0 3.9 −16.2 Source: Johansson and others 2015. Note: Results are based on the total Ethiopian population, with intervention costs equally divided among income quintiles of the population (quintile I having the lowest household income and quintile V the highest). All monetary values are expressed in 2012 US$. a. Total societal income/wealth in productive ages (15–60 years) (2012) in Ethiopia is US$879: by quintile (Q), US$281 for QI, US$536 for QII, US$772 for QIII, US$1,072 for QIV, and US$1,732 for QV. b. Net societal cost = (governmental cost) − (productivity gain). 248 Mental, Neurological, and Substance Use Disorders spending that is OOP, and the estimated cost per treated well as health gains. Across the two geographical settings case. Our initial findings from the application of ECEA and multiple disorders considered (table 13.6), and after to MNS disorders need to be interpreted with a due allowing for uncertainty, it is clear that enhanced coverage degree of caution. of effective treatment leads to significant improvements A primary aim of the preceding analysis was to ascer- in population health (1,500 and 3,000 healthy life-years tain the extent to which scaled-up and publicly funded per one million population in Ethiopia and India, respec- mental health services can contribute to greater equality tively, when the three disorders are considered together) of access to care and fairness in financial contributions as and that this can be achieved at a very reasonable cost Table 13.6 Comparative Results of Extended Cost-Effectiveness in India and Ethiopia Per one million population Disease/outcome India Ethiopia Schizophrenia Current treatment coverage (target coverage) (%) 40 (80) 1 (75) a Avertable burden (at target coverage) 249 95 b Treatment cost (at target coverage, in $, millions) 0.40 0.28 Averted OOPs (at current coverage, in $, millions)c 0.140 0.001 Insurance value (at current coverage, in $)d 24,582 0.1 e Insurance value, two lowest quintiles (% of total) 52 78 Depression Current treatment coverage (target coverage) (%) 20 (50) 1 (30) a Avertable burden (at target coverage) 1,793 649 b Treatment cost (at target coverage, in $, millions) 0.68 0.59 Averted OOPs (at current coverage, in $, millions)c 0.190 0.003 Insurance value (at current coverage, in $)d 5,400 17 e Insurance value, two lowest quintiles (% of total) 42 74 Epilepsy Current treatment coverage (target coverage) (%) 47 (80) 5 (75) a Avertable burden (at target coverage) 1,251 682 Treatment cost (at target coverage, in $, millions)b 0.30 0.34 Averted OOPs (at current coverage, in $, millions)c 0.210 0.010 d Insurance value (at current coverage, in $) 11,410 122 Insurance value, two lowest quintiles (% of total)e 60 77 Combined Avertable burden (at target coverage)a 3,293 1,425 Treatment cost (at target coverage, in $, millions)b 1.37 1.21 c Averted OOPs (at current coverage, in $, millions) 0.540 0.014 d Insurance value (at current coverage, in $) 41,392 139 e Insurance value, two lowest quintiles (% of total) 51 76 Note: Results are based on a population of one million people. All monetary values are expressed in 2012 US$. OOP = out-of-pocket. a. Averted disease burden is expressed as healthy life-years gained and is drawn from the Global Burden of Disease 2010 study for Eastern Sub-Saharan Africa (Whiteford and others 2013). b. Total cost of care = direct government expenditure associated with public financing at target coverage. c. Private expenditures averted = out-of-pocket spending that is eliminated by switching to public financing. d. Insurance value = financial risk protection provided, based on current coverage. e. Proportion of total insurance value that accrues to the two lowest income quintile groups (the poorest 40 percent of households). Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis 249 (US$1.21 per capita in Ethiopia and US$1.37 in India). • Low-income countries (LICs) = US$1,045 or less Furthermore, a UPF policy can lead to a more equita- • Middle-income countries (MICs) are subdivided: ble allocation of public health resources across income a) Lower-middle-income = US$1,046–US$4,125 groups, and benefit the lowest-income groups most in b) Upper-middle-income (UMICs) = US$4,126–US$12,745 • High-income countries (HICs) = US$12,746 or more. terms of the value of insurance, used here as a measure of financial protection: the poorest 40 percent of house- 1. For each disorder, based on data extracted from Fekadu holds receive over 50 percent of the combined value of and others (2014), we extract a prevalence ratio between insurance in India, and 76 percent in Ethiopia. income quintiles using a risk index by income quintile (Q) It should be pointed out, however, that because exist- (QI, 1.4; QII, 1.2; QIII, 1; QIV, 0.8; and QV, 0.6) applied ing treatment coverage is low (especially in Ethiopia, to the mean prevalence of each disorder (Johansson and where it is 5 percent or less), averted OOP expenditures others 2015). arising from a switch to public finance of treatment 2. The total gain in productivity by wealth quintile i due to costs will be correspondingly low (table 13.6). This again absenteeism averted is given by: Prod_Ai = AP * Incomei * points to the substantial shortage of appropriate mental Durdis * Eff * Popi * Cov, where AP is the number of days of absenteeism prevented (8.7 days); Incomei is the average health services in Ethiopia. It should also be noted that daily income in each wealth quintile i; Durdis is the average private expenditures on complementary or traditional duration of a depressive episode (8.4 months); Eff is the remedies would not be covered by such public financing, efficacy of the intervention (SSRI + cognitive therapy + and this might continue to be a significant drain on the proactive case management = 0.35); Popi is the number income or resources of some household groups. of people with depression in each wealth quintile i; and Only when a substantial increase in service cov- Cov is the target coverage of treatment (0.30). The total erage is modeled does one see the true scale of the gain in productivity by wealth quintile i due to presentee- private expenditures that would pertain in the absence ism averted is given by: Prod_Pi = PP * Incomei * Durdis of UPF. It is vital that increased financial protection * Eff * Popi * Cov, where PP is the number of full days of goes hand in hand with enhanced coverage of an presenteeism prevented by going from depressed to non- essential package of care. Improved service access depressed (1.2); and the other variables are identical to those in Prod_Ai. The estimated annual number of people without commensurate financial protection will lead with depression (ages 15–60 years) per quintile (Q) is QI, to inequitable rates of service uptake and outcomes, 900,000; QII, 771,000; QIII, 641,000; QIV, 511,000; and but improved financial protection without appropriate QV, 381,000. service scale-up will bring little improvement at all. 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Universal Health Coverage for Mental, Neurological, and Substance Use Disorders: An Extended Cost-Effectiveness Analysis 251 DCP3 Series Acknowledgments Disease Control Priorities, third edition (DCP3) We thank the many contractors and consultants compiles the global health knowledge of institu- who provided support to specific volumes in the form tions and experts from around the world, a task that of economic analytical work, volume coordination, required the efforts of over 500 individuals, includ- chapter drafting, and meeting organization: the Center ing volume editors, chapter authors, peer reviewers, for Disease Dynamics, Economics & Policy; Centre advisory committee members, and research and staff for Chronic Disease Control; Centre for Global Health assistants. For each of these contributions, we convey Research; Emory University; Evidence to Policy Initiative; our acknowledgment and appreciation. First and Public Health Foundation of India; QURE Healthcare; foremost, we would like to thank our 33 volume University of California, San Francisco; University of editors who provided the intellectual vision for their Waterloo; University of Queensland; and the World volumes based on years of professional work in their Health Organization. respective fields, and then dedicated long hours to We are tremendously grateful for the wisdom and reviewing each chapter, providing leadership and guidance provided by our advisory committee to the guidance to authors, and framing and writing the editors. Steered by Chair Anne Mills, the advisory com- summary chapters. We also thank our chapter authors mittee assures quality and intellectual rigor of the high- who collectively volunteered their time and expertise est order for DCP3. to writing over 160 comprehensive, evidence-based The National Academy of Medicine, in collaboration chapters. with the InterAcademy Medical Panel, coordinated the We owe immense gratitude to the institutional spon- peer-review process for all DCP3 chapters. Patrick Kelley, sor of this effort: The Bill & Melinda Gates Foundation. Gillian Buckley, Megan Ginivan, and Rachel Pittluck The Foundation provided sole financial support of managed this effort and provided critical and substan- the Disease Control Priorities Network. Many thanks tive input. to Program Officers Kathy Cahill, Philip Setel, Carol The World Bank External and Corporate Relations Medlin, and (currently) Damian Walker for their Publishing and Knowledge division provided excep- thoughtful interactions, guidance, and encouragement tional guidance and support throughout the demanding over the life of the project. We also wish to thank production and design process. We would particularly Jaime Sepúlveda for his longstanding support, including like to thank Carlos Rossel, the publisher; Mary Fisk, chairing the Advisory Committee for the second edition Nancy Lammers, Rumit Pancholi, and Deborah Naylor and, more recently, demonstrating his vision for DCP3 for their diligence and expertise. Additionally, we thank while he was a special advisor to the Gates Foundation. Jose de Buerba, Mario Trubiano, Yulia Ivanova, and We are also grateful to the University of Washington’s Chiamaka Osuagwu of the World Bank for providing Department of Global Health and successive chairs King professional counsel on communications and marketing Holmes and Judy Wasserheit for providing a home base strategies. for the DCP3 Secretariat, which included intellectual Several U.S. and international institutions contrib- collaboration, logistical coordination, and administra- uted to the organization and execution of meetings that tive support. supported the preparation and dissemination of DCP3. 253 We would like to express our appreciation to the reproductive and maternal health volume consulta- following institutions: tion, November 2013) • National Cancer Institute, cancer consultation • University of Bergen, consultation on equity (June (November 2013) 2011) • Union for International Cancer Control, cancer con- • University of California, San Francisco, surgery sultation (November 2013, December 2014) volume consultations (April 2012, October 2013, February 2014) Carol Levin provided outstanding governance for cost • Institute of Medicine, first meeting of the Advisory and cost-effectiveness analysis. Stéphane Verguet added Committee to the Editors (March 2013) invaluable guidance in applying and improving the • Harvard Global Health Institute, consultation on extended cost-effectiveness analysis method. Shane Murphy, policy measures to reduce incidence of noncommu- Zachary Olson, Elizabeth Brouwer, Kristen Danforth, and nicable diseases (July 2013) David Watkins provided exceptional research assistance • Institute of Medicine, systems strengthening meeting and analytic assistance. Brianne Adderley ably managed (September 2013) the budget and project processes. The efforts of these indi- • Center for Disease Dynamics, Economics & Policy viduals were absolutely critical to producing this series, and (Quality and Uptake meeting, September 2013; we are thankful for their commitment. 254 DCP3 Series Acknowledgments Series and Volume Editors VOLUME EDITORS Ramanan Laxminarayan Ramanan Laxminarayan is Vice President for Research Vikram Patel and Policy at the Public Health Foundation of India, and Vikram Patel is Professor of International Mental he directs the Center for Disease Dynamics, Economics Health and Wellcome Trust Principal Research Fellow & Policy in Washington, DC, and New Delhi. His at the London School of Hygiene & Tropical Medicine research deals with the integration of epidemiological (LSHTM). He is a psychiatrist whose work focuses on models of infectious diseases and drug resistance into the epidemiology and treatment of mental disorders in the economic analysis of public health problems. He was low-resource settings. He was the Founding Director of one of the key architects of the Affordable Medicines the Centre for Global Mental Health at the LSHTM and Facility–malaria, a novel financing mechanism to is the Co-Director of the Centre for Control of Chronic improve access and delay resistance to antimalarial Conditions at the Public Health Foundation of India. drugs. In 2012, he created the Immunization Technical In 2011, Dr. Patel served on the Government of India’s Support Unit in India, which has been credited with Mental Health Policy group, which produced India’s first improving immunization coverage in the country. He national mental health policy in 2014. teaches at Princeton University. Dan Chisholm María Elena Medina-Mora Dan Chisholm is a Health Systems Adviser in the María Elena Medina-Mora is the General Director for Department of Mental Health and Substance Abuse the National Institute of Psychiatry Ramón de la Fuente at the World Health Organization. His main areas of Muñiz in Mexico. She is a member of the National System work include development and monitoring of global of Researchers. Dr. Medina-Mora is a full researcher of the mental health plans and activities, technical assistance to National Institutes of Health and has a teaching appoint- Member States on mental health system strengthening, ment in the National Autonomous University of Mexico and analysis of the costs and cost-effectiveness of strate- and as Adjunct Professor in the Harvard T. H. Chan gies for reducing the global burden of mental disorders School of Public Health. She is also member of the World and other noncommunicable diseases. Health Organization’s Expert Committee on Addictions. Tarun Dua SERIES EDITORS Tarun Dua is a Medical Officer working in the Evidence, Research and Action on Mental and Brain Disorders Dean T. Jamison unit in the Department of Mental Health and Substance Dean T. Jamison is a Senior Fellow in Global Health Abuse at the World Health Organization. Dr. Dua serves Sciences at the University of California, San Francisco, as the focal point for neurological disorders in the and an Emeritus Professor of Global Health at the organization. University of Washington. He previously held academic 255 appointments at Harvard University and the University and the International Development Research Centre, of California, Los Angeles; he was an economist on the among others, in work carried out in over 20 low- and staff of the World Bank, where he was lead author of the middle-income countries. She led the work on nutrition World Bank’s World Development Report 1993: Investing for the Copenhagen Consensus in 2008, when micronu- in Health. He was lead editor of DCP2. He holds a PhD trients were ranked as the top development priority. She in economics from Harvard University and is an elected has served as Associate Provost of Graduate Studies at member of the Institute of Medicine of the National the University of Waterloo, Vice-President Academic at Academy of Sciences. He recently served as Co-Chair Wilfrid Laurier University in Waterloo, and interim dean and Study Director of The Lancet’s Commission on at the University of Toronto Scarborough. Investing in Health. Prabhat Jha Rachel Nugent Prabhat Jha is the Founding Director of the Centre for Rachel Nugent is a Research Associate Professor in Global Health Research at St. Michael’s Hospital and the Department of Global Health at the University holds Endowed and Canada Research Chairs in Global of Washington. She was formerly Deputy Director of Health in the Dalla Lana School of Public Health at Global Health at the Center for Global Development, the University of Toronto. He is Lead Investigator of Director of Health and Economics at the Population the Million Death Study in India, which quantifies the Reference Bureau, Program Director of Health and causes of death and key risk factors in over two mil- Economics Programs at the Fogarty International lion homes over a 14-year period. He is also Scientific Center of the National Institutes of Health, and senior Director of the Statistical Alliance for Vital Events, which economist at the Food and Agriculture Organization of aims to expand reliable measurement of causes of death the United Nations. From 1991–97, she was Associate worldwide. His research includes the epidemiology and Professor and Department Chair in Economics at Pacific economics of tobacco control worldwide. Lutheran University. She has advised the World Health Organization, the U.S. government, and nonprofit orga- nizations on the economics and policy environment of Ramanan Laxminarayan noncommunicable diseases. See the list of Volume Editors. Hellen Gelband Charles N. Mock Hellen Gelband is Associate Director for Policy at the Charles N. Mock, MD, PhD, FACS, has training as both a Center for Disease Dynamics, Economics & Policy trauma surgeon and an epidemiologist. He worked as a (CDDEP). Her work spans infectious disease, particu- surgeon in Ghana for four years, including at a rural hos- larly malaria and antibiotic resistance, and noncommu- pital (Berekum) and at the Kwame Nkrumah University nicable disease policy, mainly in low- and middle-income of Science and Technology (Kumasi). In 2005−07, he countries. Before joining CDDEP, then Resources for the served as Director of the University of Washington’s Future, she conducted policy studies at the (former) Harborview Injury Prevention and Research Center. In Congressional Office of Technology Assessment, the 2007−10, he worked at the World Health Organization Institute of Medicine of the National Academies, and a (WHO) headquarters in Geneva, where he was respon- number of international organizations. sible for developing the WHO’s trauma care activi- ties. In 2010, he returned to his position as Professor of Surgery (with joint appointments as Professor of Susan Horton Epidemiology and Professor of Global Health) at the Susan Horton is Professor at the University of Waterloo University of Washington. His main interests include the and holds the Centre for International Governance spectrum of injury control, especially as it pertains to Innovation (CIGI) Chair in Global Health Economics low- and middle-income countries: surveillance, injury in the Balsillie School of International Affairs there. prevention, prehospital care, and hospital-based trauma She has consulted for the World Bank, the Asian care. He is President (2013−15) of the International Development Bank, several United Nations agencies, Association for Trauma Surgery and Intensive Care. 256 Series and Volume Editors Contributors Emiliano Albanese Metrics and Evaluation, University of Washington, Department of Psychiatry, University of Geneva, Seattle, Washington, United States Geneva, Switzerland Catherine O. Egbe Margaret Barry University of KwaZulu-Natal, Durban, South Africa; National University of Ireland Galway, Galway, Ireland Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, Amanda J. Baxter California, United States School of Public Health, University of Queensland, Brisbane, Queensland, Australia; Queensland Centre for Holly E. Erskine Mental Health Research, Wacol, Queensland, Australia School of Public Health, University of Queensland, Vladimir Carli Herston, Queensland, Australia; Institute for Health Swedish National Center for Suicide Research and Metrics and Evaluation, University of Washington, Prevention, Karolinska Institutet, Stockholm, Sweden Seattle, Washington, United States Fiona J. Charlson Sara Evans-Lacko School of Public Health, University of Queensland, Centre for Global Mental Health, Institute of Psychiatry, Herston, Queensland, Australia; Institute for Health Psychology, and Neuroscience, King’s College London, Metrics and Evaluation, University of Washington, London, United Kingdom Seattle, Washington, United States Valery Feigin Pamela Y. Collins National Institute for Stroke and Applied U.S. National Institute of Mental Health, Bethesda, Neurosciences, Auckland University of Technology, Maryland, United States Auckland, New Zealand Abigail Colson Abebaw Fekadu Center for Disease Dynamics, Economics & Policy, Addis Ababa University, Addis Ababa, Ethiopia Washington, DC, United States; Department of Management Science, University of Strathclyde, Alize J. Ferrari Glasgow, Scotland School of Public Health, University of Queensland, Herston, Queensland, Australia; Institute for Health Louisa Degenhardt Metrics and Evaluation, University of Washington, National Drug and Alcohol Research Centre, Seattle, Washington, United States University of New South Wales Australia, Sydney, New South Wales, Australia; Melbourne School Panteleimon Giannakopoulos of Population and Global Health, University of Department of Psychiatry, University of Geneva, Melbourne, Victoria, Australia; Institute for Health Geneva, Switzerland 257 Petra Gronholm Cathrine Mihalopoulos Centre for Global Mental Health, Institute of Psychiatry, Deakin University, Melbourne, Victoria, Australia Psychology, and Neuroscience, King’s College London, London, United Kingdom Maristela Monteiro Pan American Health Organization, Washington DC, David Gunnell United States University of Bristol, Bristol, United Kingdom Aditi Nigam Wayne D. Hall Center for Disease Dynamics, Economics & Policy, Centre for Youth Substance Abuse Research, University Washington, DC, United States of Queensland, Brisbane, Queensland, Australia Rachana Parikh Steven Hyman Public Health Foundation of India, New Delhi, Stanley Center for Psychiatric Research, Broad Institute India of MIT and Harvard and Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, Inge Petersen Massachusetts, United States University of KwaZulu-Natal, Durban, South Africa David Jernigan Michael R. Phillips Johns Hopkins Bloomberg School of Public Health, Shanghai Mental Health Center, Shanghai Jiao Tong Johns Hopkins University, Baltimore, Maryland, University School of Medicine, Shanghai, China; United States Departments of Psychiatry and Global Health, Nathalie Jette Emory University, Atlanta, Georgia, United States University of Calgary, Calgary, Alberta, Canada Martin J. Prince Kjell Arne Johansson Institute of Psychiatry, Psychology, and Neuroscience, University of Bergen, Bergen, Norway King’s College London, London, United Kingdom Carol Levin Atif Rahman Department of Global Health, University of University of Liverpool, Liverpool, United Kingdom Washington, Seattle, Washington, United States Neha Raykar Mattias Linde Public Health Foundation of India, New Delhi, Department of Neuroscience, Norwegian University India of Science and Technology, Trondheim, Norway; Norwegian Advisory Unit on Headaches, St. Olavs Tania Real Hospital, Trondheim, Norway National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico Crick Lund Department of Psychiatry and Mental Health, Alan Jürgen Rehm J. Flisher Centre for Public Mental Health, University Centre for Addiction and Mental Health, Toronto, of Cape Town, Cape Town, South Africa; Centre Ontario, Canada for Global Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, Jacqueline Roberts London, United Kingdom Autism Centre of Excellence, Griffith University, Brisbane, Queensland, Australia John Marsden National Addiction Centre, King’s College London, Robin Room London, United Kingdom Centre for Alcohol Policy Research, La Trobe University, Melbourne, Victoria, Australia; Centre for Itamar Megiddo Social Research on Alcohol and Drugs, Stockholm Center for Disease Dynamics, Economics & Policy, University, Stockholm, Sweden Washington, DC, United States; Department of Management Science, University of Strathclyde, Diego Sánchez-Moreno Glasgow, Scotland Ministry of Health, Mexico City, Mexico 258 Contributors James G. Scott John Strang University of Queensland Centre for Clinical Research, National Addiction Centre, King’s College London, Brisbane, Queensland, Australia; Metro North Mental London, United Kingdom Health, Royal Brisbane and Women’s Hospital, Kiran T. Thakur Brisbane, Queensland, Australia Columbia University College of Physicians and Maya Semrau Surgeons, New York, New York, United States Centre for Global Mental Health, Institute of Psychiatry, Graham Thornicroft Psychology, and Neuroscience, King’s College London, Centre for Global Mental Health, Institute of Psychiatry, London, United Kingdom Psychology, and Neuroscience, King’s College London, Rahul Shidhaye United Kingdom Public Health Foundation of India, New Delhi, India; Stéphane Verguet CAPHRI School for Public Health and Primary Care, Department of Global Health and Population, Maastricht University, Maastricht, the Netherlands Harvard T. H. Chan School of Public Health, Boston, Morton M. Silverman Massachusetts, United States Suicide Prevention Resource Center, Education Lakshmi Vijayakumar Development Center, Waltham, Massachusetts, United SNEHA, Voluntary Health Services, Chennai, India; States, The University of Colorado Denver School of Centre for Youth Mental Health, University of Medicine, Aurora, Colorado, United States; The Jed Melbourne, Melbourne, Victoria, Australia Foundation, New York, New York, United States Theo Vos Timothy J. Steiner Institute for Health Metrics and Evaluation, University Norwegian University of Science and Technology, of Washington, Seattle, Washington, United States Trondheim, Norway; Imperial College London, London, United Kingdom Harvey A. Whiteford School of Public Health, University of Queensland, Emily Stockings Herston, Queensland, Australia; Queensland Centre National Drug and Alcohol Research Centre, University for Mental Health Research, Wacol, Queensland, of New South Wales, Sydney, Australia Australia; Institute for Health Metrics and Evaluation, Kirsten Bjerkreim Strand University of Washington, Seattle, Washington, University of Bergen, Bergen, Norway United States Contributors 259 Advisory Committee to the Editors Anne Mills, Chair Roger Glass Professor, London School of Hygiene & Tropical Director, Fogarty International Center, National Medicine, London, United Kingdom Institutes of Health, Bethesda, Maryland, United States Olusoji Adeyi Amanda Glassman Director, Health, Nutrition, and Population Global Director, Global Health Policy, Center for Global Practice, World Bank, Washington, DC, United States Development, Washington, DC, United States Kesetebirhan Admasu Glenda Gray Minister of Health, Addis Ababa, Ethiopia Executive Director, Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Johannesburg, George Alleyne South Africa Director Emeritus, Pan American Health Organization, Washington, DC, United States Demissie Habte Chair of Board of Trustees, International Clinical Ala Alwan Epidemiological Network, Addis Ababa, Ethiopia Director, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Arab Republic Richard Horton of Egypt Editor, The Lancet, London, United Kingdom Rifat Atun Edward Kirumira Professor, Global Health Systems, Harvard University, Dean, Faculty of Social Sciences, Makerere University, Boston, Massachusetts, United States Kampala, Uganda Zulfiqar Bhutta Peter Lachmann Chair, Division of Women and Child Health, Aga Khan Professor, University of Cambridge, Cambridge, University Hospital, Karachi, Pakistan United Kingdom Agnes Binagwaho Lai Meng Looi Minister of Health, Kigali, Rwanda Professor, University of Malaya, Kuala Lumpur, Malaysia Mark Blecher Senior Health Advisor, South Africa Treasury Adel Mahmoud Department, Cape Town, South Africa Senior Molecular Biologist, Princeton University, Princeton, New Jersey, United States Patricia Garcia Dean, School of Public Health, Universidad Peruana Anthony Measham Cayetano Heredia, Lima, Peru World Bank, Washington, DC, United States (retired) 261 Carol Medlin Jaime Sepúlveda Senior Health and Nutrition Specialist, Executive Director, Global Health Sciences, University Health, Nutrition, and Population Global Practice, of California, San Francisco, San Francisco, California, World Bank, Washington, DC, United States United States Alvaro Moncayo Richard Skolnik Researcher, Universidad de los Andes, Bogotá, Lecturer, Health Policy Department, Yale School of Colombia Public Health, New Haven, Connecticut, United States Jaime Montoya Stephen Tollman Executive Director, Philippine Council for Health Professor, University of the Witwatersrand, Research and Development, Taguig City, the Johannesburg, South Africa Philippines Jürgen Unutzer Ole Norheim Professor, Department of Psychiatry, University of Professor, University of Bergen, Bergen, Norway Washington, Seattle, Washington, United States Folashade Omokhodion Damian Walker Professor, University College Hospital, Ibadan, Senior Program Officer, Bill & Melinda Gates Nigeria Foundation, Seattle, Washington, United States Toby Ord Ngaire Woods President, Giving What We Can, Oxford, Director, Global Economic Governance Programme, United Kingdom Oxford University, Oxford, United Kingdom K. Srinath Reddy Nopadol Wora-Urai President, Public Health Foundation of India, Professor, Department of Surgery, Phramongkutklao New Delhi, India Hospital, Bangkok, Thailand Sevkat Ruacan Kun Zhao Dean, Koç University School of Medicine, Istanbul, Researcher, China National Health Development Turkey Research Center, Beijing, China 262 Advisory Committee to the Editors Reviewers Sergio Aguilar-Gaxiola Alexander Grinshpoon University of California, Davis, School of Medicine, Israel Institute of Technology, Haifa, Israel Sacramento, California, United States Yasemin Gürsoy-Özdemir Pierre K. Alexandre Department of Neurology, Koç University School of Management Department, College of Business, Medicine, Istanbul, Turkey Florida Atlantic University, Boca Raton, Florida, Murad M. Khan United States Aga Khan University, Karachi, Pakistan Peter Anderson Rena Kurs Newcastle University, Institute for Health and Society, Sha’ar Menashe Mental Health Center, Sha’ar Menashe, Newcastle, United Kingdom Israel Margaret Barry David Leon National University of Ireland Galway, School of Health London School of Hygiene & Tropical Medicine, Sciences, Galway, Ireland London, United Kingdom Angelina Brotherhood Ron Manderscheid Centre for Public Health, Liverpool John Moores National Association of County Behavioral Health and University, Liverpool, United Kingdom Developmental Disability Directors, Washington, DC, United States Anja Busse United Nations Office on Drugs and Crime, Vienna, Pallab K. Maulik Austria George Institute for Global Health, India, New Delhi, India Dixon Chibanda Department of Community Medicine, University of David McDaid Zimbabwe, Harare, Zimbabwe London School of Economics and Political Science, London, United Kingdom Mary De Silva Centre for Global Mental Health, London School Nicole M. Monteiro of Hygiene & Tropical Medicine, London, Center for Healing and Development, Washington, DC, United Kingdom United States Tedla W. Giorgis Chiadi U. Onyike Office of the Minister, Ministry of Health, Addis Ababa, The Johns Hopkins Hospital, Baltimore, Maryland, Ethiopia United States 263 Gregory Simon Steven D. Vannoy Group Health Research Institute, Seattle, Washington, University of Massachusetts, Boston, Boston, United States Massachusetts, United States Jürgen Unützer Chiu-Wan Ng Department of Psychiatry and Behavioral Sciences, Faculty of Medicine, University Malaya, Kuala Lumpur, University of Washington, Seattle, Washington, Malaysia United States 264 Reviewers Index Boxes, figures, notes, and tables are indicated by b, f, n, and t respectively. A occupational therapy, 76, 79 ACE (Assessing Cost-Effectiveness) prevention packages of care, 76–77 framework, 188 pharmacologic and psychological treatment, acupuncture, 91, 101 74–76, 75–76t, 79 addiction. See illicit drug dependence population platform interventions, 73 ADHD. See attention-deficit hyperactivity disorder schools, 73–74 adolescents workplace, 73 ADHD and, 146 mood and anxiety disorders, 68–72 alcoholic consumption, heavy episodic drinking anxiety disorders, 70–71. See also anxiety by, 128 disorders CBT for depression in, 222 bipolar disorder, 71–72. See also bipolar disorder health loss in, 36 depressive disorder, 69–70. See also depression interventions for psychotic disorders, 72–73 drug use, early intervention for at-risk youth, 114 recommendations for, 78–79 mental health policies and plans, 148 risk factors, 68 onset, 8, 194 schizophrenia, 72–73. See also schizophrenia Resourceful Adolescent Programme-Adolescent suicide and, 169 version (RAP-A) program, 229–30, 230t training gatekeepers to identify people with, 223 suicides of, 171 YLDs and, 67–68, 68f adult mental disorders, 67–86 advertising bans on alcoholic beverages, 139 burden of disease, 67–68 AEDs (anti-epileptic drugs), 88, 90, 91, 240 extended-stay facilities to treat, 203 affordability. See cost-effectiveness and affordability of interventions for, 73–78 interventions case detection and diagnosis, 77 Africa. See also specific countries and regions collaborative and stepped care, 77 alcohol consumption in, 129 community outreach, 77–78, 79 epilepsy in, 90 community platform interventions, 73–74 illicit drug trade in, 111 cost-effectiveness of, 78 migraines in, 100 early intervention services, 77 suicide prevention organizations in, 176 family, 74, 79 suicide rates in, 164, 169, 170 health care platform interventions, 74–78 age as factor. See also adolescents; elderly persons information and communication packages, 78 for anxiety disorders, 70–71 mental health awareness campaigns, 73 for cause-specific deaths from MNS disorders, mental health legislation, 73 53, 54t 265 childhood disorders resulting in adult disorders, pricing and market regulation, 138 146, 194 primary health care, 13–14t, 15 for dementia, 8 prohibition and partial bans, 131, 132t of suicide and self-harm, 164, 165t, 166–67f, 166f quasi-experimental studies, 130 Alcoholics Anonymous, 137 reducing availability of alcohol, 131 alcohol use disorders, 127–43 school-based, 19, 139 age of death attributable to, 53, 54t screening and brief interventions, 135–36, 136t, binge drinking, 49, 128 139, 140 burden of disease, 32–34t, 128–30 self-help and support groups, 136–37 challenges for LMICs, 138–39 sobriety checkpoints, 134 classification of beverages, 127 specialist health care delivery, 15 consequences, 129 suspension of driver’s license, 135 co-occurring disorders and, 49–50 taxation, 131t, 132–33, 138, 221, 229 cost-effectiveness of interventions for, 19, 20f, warning labels, 135, 139 137–38, 139–40, 221–22, 226, 227t liver cirrhosis and, 50 DALYs and, 129 patterns of, 128 deaths associated with, 7t, 44, 129 prohibition and partial bans, 131, 132t fetal alcohol syndrome disorders (FASD), 128, public health considerations, 128 135, 139 quasi-experimental studies, 130 GBD findings of excess mortality for recommendations for LMICs, 139 estimated number of cause-specific and excess societal response, 130 deaths, 46t, 49 suicide and, 50, 129, 169, 175 gender differences, 45, 46f unintentional injuries and violence, 50, 129 gender differences, 128–29 YLLs and, 43–45, 45f, 53, 55, 55t globalization of alcohol beverages industry, 128 Alzheimer’s disease. See also dementia indigenous communities and burden of disease, 32–34t, 94 community platform interventions, 135, 136t DALYs and, 95 prohibition, 131, 131t deaths associated with, 7t, 37, 53, 54t industry role, 127–28 goal to identify cure by 2025, 99 interventions for, 130–37 pharmacological interventions, 96, 98 advertising bans, 139 amphetamine dependence. See also illicit drug availability control and licensing of sellers, 138 dependence blood alcohol concentration (BAC) testing of amphetamine-type stimulants, 109 drivers, 134 burden of disease, 32–34t breath testing of drivers, 134 consumption trends, 111 community platform interventions, 130–31, deaths associated with, 7t, 110 135, 136t age of death, 54t control of unrecorded market, 133, 138–39 estimated number of cause-specific and excess cross-border shopping, 133 deaths for, 46t, 50f delivery platforms, 14t prevalence in Southeast Asia and Australasia, 37 demand reduction strategies, 229, 229f rates of dependence, 110 driving countermeasures, 134–35, 139 YLLs and, 43 education campaigns, 139 Anderson, P., 19 family-based interventions, 135, 139 anorexia nervosa, 3. See also eating disorders health care platform interventions, 135–37 antidepressants. See depression individual-based, 130 anti-epileptic drugs (AEDs), 88, 90, 91, 240 law enforcement measures to reduce driving antipsychotics while impaired, 132t for dementia patients, 53, 96–97 mass media campaigns, 135 for schizophrenia, 48 medical and social detoxification, follow-up, anxiety disorders, 70–71 and referral, 136, 137t, 139 age of onset, 70–71 population platform interventions, 130, burden of disease, 32–34t, 36, 70–71 131–35, 131t childhood, 145 pregnant women and, 135, 139 clinical features and course, 70 266 Index DALYs associated with, 36 planning and consultation with primary health care deaths associated with, 7t staff in, 210 epidemiological surveys on, 38 Positive Parenting Program (Triple P), 223 epidemiology, 70–71 autistic spectrum disorders estimated number of cause-specific and excess age of cause-specific and excess deaths deaths for, 46t, 49 attributed to, 47f gender differences, 68 burden of disease, 32–34t, 36 generalized anxiety disorder, 70 co-occurring disorders with, 48–49 interventions for, 9t. See also adult mental disorders deaths associated with, 7t limited access to, 12 estimated number of cause-specific and excess pharmacologic and psychological treatment, deaths for, 46t, 47f, 48–49 74–76, 75t interventions for, 9t primary health care, 13–14t, 15 self-care, 15 B obsessive-compulsive disorder (OCD), 70 Babor, T. F., 135 panic disorder, 70 Baker-Henningham, H., 150 simple phobias, 70 Balanced Care Model, 207 social anxiety disorder, 70 Beijing Suicide Research and Prevention Center, 176 YLDs and, 68, 68f best practice interventions, 4b, 12, 15, 22, 56, 183, Asia. See also specific countries and regions 184t, 188 amphetamine dependence in, 37 binge drinking, 49, 128 drug users, detention and treatment of, 58 bipolar disorder, 2 illicit substance use in, 111 ADHD and, 49 Asperger’s syndrome, 36. See also autistic spectrum adult bipolar disorder, 71–72 disorders age of cause-specific and excess deaths attributed aspirin, 100–101 to, 47f Assessing Cost-Effectiveness (ACE) prevention burden of disease, 32t, 34t, 71–72 framework, 188 clinical features and course, 71 Atkins diet, 91 cost-effectiveness of interventions for, 19, 227t Atlas on Substance Use (WHO), 137 community-based vs. hospital-based services, 228 attention-deficit hyperactivity disorder (ADHD) deaths associated with, 7t age of occurrence, 146 epidemiology, 71–72 bipolar disorder and, 49 estimated number of cause-specific and excess burden of disease, 32–34t, 36 deaths for, 46t, 47f, 48 cost-effectiveness of pharmacological gender differences, 68 interventions, 155 interventions for. See also adult mental disorders defined, 145 pharmacologic and psychological treatment, estimated number of cause-specific and excess 74–76, 75t deaths for, 46t, 49 specialist health care delivery, 15 interventions for, 9t, 12 YLDs and, 68, 68f medications, 154 birth trauma, 185 school-based, 192 blood alcohol concentration (BAC) testing of Australia drivers, 134 collaborative stepped care approach in, 210 Boussinesq, M., 52 drug dependence in Brazil court-mandated treatment, 113 childhood mental and developmental disorders in economic costs, 111 CBT for children with anxiety disorders, 154 interventions, cost of, 118, 119 community-based interventions, 149 indigenous communities and alcohol consumption collaborative stepped care approach in, 210 in, 131 cost-effectiveness of drug therapy for schizophrenia mental health first aid course in, 188 and depression in, 225 methadone maintenance and buprenorphine primary care interventions in, 208 maintenance in, 226 training of primary care workers, 210 parenting interventions in, 155, 223 specialists training primary health care staff in, 210 Index 267 suicide in, 169, 170, 171, 172 Cause of Death Ensemble Modeling (CODEm), 42 Program for Promotion of Life and Suicide CBT. See cognitive behavioral therapy Prevention, 176 Central/Eastern Europe and Central Asia teacher training program to identify and assess alcohol-related deaths in, 44, 55 mental health problems in, 191b cost-effectiveness of interventions in, 221, 227t breath testing of drivers, 134 suicide of women in, 171 brief psychological intervention YLL rates in, 44, 45–46f, 55 for alcohol use disorders, 135–36, 136t, 139, 140 child abuse, 68, 146, 148, 152 for drug dependence, 115, 116t, 117 Child and Adolescent Mental Health Policies and Plans for suicide, 177 (WHO), 148 Building Back Better (WHO), 204 childhood mental and developmental disorders, bullying, 150, 156, 189 145–61. See also attention-deficit hyperactivity buprenorphine maintenance, 57, 117, 118, 119, 226 disorder (ADHD); autistic spectrum disorders burden of MNS disorders, 4–5b, 5–8, 22, 29–40. See also anxiety disorders, 145, 146 mortality rates bullying, 150, 156, 189 adult mental disorders, 67–68 burden of disease, 146 alcohol use disorders, 32–34t, 128–30 consequences of, 146–47 childhood mental and developmental disorders, 146 cost-effectiveness of interventions, 155–56 depression, 69–70 epidemiology, 146 Global Burden of Disease Study 2010 (GBD 2010), gender differences in, 5, 33, 146, 147t 29–30. See also Global Burden of Disease interventions for, 9–10t, 12, 149–55, 149b, 156t Study 2010 child and adolescent mental health policies and illicit drug dependence, 32, 32–34t, 34, 111, 118 plans, 148 implications of study findings, 36–37 child protection legislation, 148–49 limitations of study and directions for future cognitive behavioral therapy (CBT), 153–55, 156 research, 37–38 community platform interventions, 149–51 methodology of study, 30–31 delivery platforms, 13t neurological disorders, 87 early child development, 149–50 overview, 29–30 early intervention strategies, importance of, 36 Burundi, integration of mental health care into health care platform interventions, 151–54 primary care program, 17b maternal mental health interventions, 152–53, 212 C medications for ADHD, 154 Canada medications for conduct disorder, 154 cost of Alzheimer’s disease treatment in, 98 multisystem therapy, 155 fetal alcohol syndrome (FAS) warning labels in, 135 parenting skills training, 152, 213–14 TEAMcare Canada, 213 population platform interventions, 148–49 cancer, 41, 48, 49, 56 problem-solving skills therapy (PSST), 155 cannabis dependence. See also illicit drug dependence psychosocial treatments for conduct disorder, burden of disease, 32–34t 154–55 cannabis products, 109 school-based interventions, 150. See also deaths associated with, 7t, 110 education and schools estimated number of cause-specific and excess screening and community rehabilitation for deaths for, 46t developmental disorders, 151–52, 156 medications for, 118 specialist health care, 154–55 rates of dependence, 110 Ten Questions screen, 151, 151b schizophrenia and, 53, 55t voluntary sector programs, 150 cardiovascular disease, 48, 51, 52, 56, 213 nature of, 146 Carroll, A. E., 150 risk factors for, 146–48, 148t case studies. See also Ethiopia; India trends, 148 scaling up interventions for MNS disorders, types of, 145 16–17b, 24 Chile catastrophic financial effects, 2b CBT depression program in, 222 268 Index National Depression Detection and Treatment communicable compared to noncommunicable Program, 16–17b, 213 diseases in global burden of disease, 30, 36, 41 postpartum depression interventions in, 153, 207–8 community-based care school-based interventions in, 192 for childhood mental and developmental disorders, suicide rates in, 169 151–52, 156 China compared to hospital level of care, 228 alcohol consumption in, 129 for illicit drug dependence, 114–15, 116t taxation, 133 residential facilities, 15–16, 203 violence associated with, 129 community outreach teams, 16, 56, 77–78, 79 Central Government Support for the Local community platform interventions, 13–14t, 15, Management and Treatment of Severe 187–92, 194 Mental Illnesses Project, 16b adult mental health, 73–74 depression, treatment of, 70 alcohol use disorders, 130–31, 135, 136t drowning as premature cause of death in, 52 childhood mental and developmental disorders, headache interventions in, 102, 208, 228b 149–51 suicide in, 164, 168, 170, 172, 175, 177 gender equity and economic empowerment survey of mental disorders in, 38 interventions, 193 Chisholm, D., 19, 232 identification and case detection, 193 CHOosing Interventions that are Cost-Effective illicit drug dependence, 113–14, 115t (CHOICE) project (WHO), 220, 226, 228, neighborhood groups, 192–93, 194 228b, 232 parenting. See parenting interventions chronic or relapsing course, 1 in schools. See education and schools cocaine dependence. See also illicit drug dependence suicide and, 175–76 age of death attributable to, 54t treatment, care, and rehabilitation, 193 burden of disease, 32–34t workplace. See workplace consumption trends, 111 comparative risk assessments (CRAs), 6, 37, 42, deaths associated with, 7t 55t, 59 estimated number of cause-specific and excess counterfactual burden and, 44, 53–56 deaths for, 46t, 50f competency-based education, 209–10, 209t pharmacotherapies conduct disorders effectiveness for, 58 burden of disease, 32–34t, 36 for psychostimulant dependence, 118 childhood, 145 prevalence in North American and Latin deaths associated with, 7t America, 37 defined, 145 rates of dependence, 110 estimated number of cause-specific and excess YLLs and, 43 deaths for, 46t, 49 Cochrane Collaboration review, 207 interventions for, 9t CODEm (Cause of Death Ensemble Modeling), 42 contingency management approach to drug cognitive behavioral therapy (CBT) dependence, 117 for adult mental disorders, 76 continuous quality improvement, 214 for childhood mental and developmental disorders, Convention on the Rights of Persons with 153–55, 156 Disabilities, 215 for depression, 225 co-occurring disorders, 1, 8, 12, 47 in adolescents, 222 alcohol use disorders and, 49 for illicit drug dependence, 117 autistic spectrum disorders and, 48–49 maternal and child health programs, 212 bipolar disorders and, 48 school-based, 192 dementia and, 52–53 workplace, 188, 189 epilepsy and, 52 cognitive rehabilitation for dementia, 97, 213 integrating mental health into health programs collaborative care models, 56, 77, 79, 207 for, 212–14 collaborative stepped care, 15, 77, 207–9, 213 schizophrenia and, 48 Colombia, cost-effectiveness analysis of coping strategies and well-being, 172 antidepressants in, 225 Corrigan, P. W., 187 Index 269 cost-effectiveness and affordability of interventions, DART-AD (dementia antipsychotic withdrawal trial) 12, 18–19, 20f, 219–36 trial, 53 for adult mental disorders, 78 decriminalization of suicide, 175 affordability, 229–31 Degenhardt, L., 31 alcohol use, demand reduction strategies for, dementia, 93–99. See also Alzheimer’s disease 229, 229f age of death attributable to, 53, 54t costs of scaling up, 232f premature death, 41 school-based social and emotional learning age of onset, 8 interventions, 229–30 burden of disease, 30, 32–34t, 87, 94–95, 94f, 95 of alcohol-related legislation, 221–22 caregiver stress, 95, 97 for alcohol use disorders, 19, 20f, 137–38, 139–40, coping strategy program, cost-effectiveness 221–22 of, 225 for childhood mental and developmental disorders, community health workers’ detection abilities, 193 155–56 co-occurring disorders and, 52–53 CHOosing Interventions that are Cost-Effective cost-effectiveness of interventions for, 98–99 (CHOICE) project (WHO), 220, 226, 228, cost of, 8 228b, 232 definitions of, 31, 93–94 collaborative care models, 56 detection and diagnosis, 96 community-based parenting programs, 222–23 early-onset dementia, 94 for dementia, 98–99 epidemiology, 94–95 economic evaluation of treatment and GBD findings of excess mortality for prevention, 18b estimated number of cause-specific and excess for epilepsy, 19, 20f, 58, 90, 93 deaths, 46t, 51f, 52–53 extended cost-effectiveness analysis (ECEA), implications, 58 19, 21f, 238 interventions for, 10t, 96–98, 186 financial risk protection, 19 capacity of health care teams, 97–98 for headache disorders, 102 caregivers, 97 for illicit drug dependence, 118, 120 community-based programs, 98 lack of evidence, 12–15, 21 health care delivery interventions, 97 limitation of conventional cost-effectiveness integration into health care, 213 analysis, 220 nonpharmacological interventions, 97 for MNS disorders, 223–29 other interventions, 98–99 by country, 224f pharmacological interventions, 96–97, 98 international studies, 226 specialist health care delivery, 15 national studies, 224–26 recommendations for, 103 primary health care, 224–27 YLLs and, 43, 45f nonspecialized treatment settings, 230–31 dementia antipsychotic withdrawal trial (DART-AD) overview, 219–20 trial, 53 paucity of trials, 219, 222, 230 Dementia Society of Goa, 207 population and community levels, 220–23 demographic factors, 3b school-based social and emotional learning depression, 69–70. See also bipolar disorder; interventions, 222, 229–30 postpartum depression specialist health care delivery, 228–29 age of cause-specific and excess deaths attributed costs of mental health care, 237–38 to, 47f counseling sessions, 76 alcohol use disorders and, 49–50 court-mandated treatment for drug dependence, 112t, 113 antidepressants, 56, 75t, 225, 226 criminal activity related to illicit drugs, 111, 119 burden of disease, 32, 32–34t, 34, 36 criminal justice platforms, 112t, 113 chronic illnesses associated with, 68 cross-border shopping for alcohol, 133 clinical features and course, 69 co-occurring disorders with, 47, 56, 69 D cost-effectiveness of interventions for, 19, 20f, DALYs. See disability-adjusted life years 227t, 230 DARE (Drug Abuse Resistance Education) antidepressants and CBT, 225, 226 program (US), 114 enhanced financial and service coverage, 243–44 270 Index DALYs associated with, 36 driving impaired and traffic accidents, 49, 129, 137 deaths associated with, 6, 7t cost-effectiveness of countermeasures, 221 epidemiological surveys on, 38 countermeasures for, 134–35, 139 epidemiology and burden of disease, 69–70 helmet laws, 186 estimated number of cause-specific and excess Drug Abuse Resistance Education (DARE) program deaths for, 46t, 47f, 49 (US), 114 gender differences, 68 drug dependence. See illicit drug dependence interventions for, 8, 9t, 12, 75t drug education, 114, 115t collaborative care, 207 drug testing electroconvulsive therapy (ECT), 74 of offenders, 112t, 113 European Alliance against Depression in workplace, 113–14, 115t Programme, 176 Drummond, M. F., 220 limited access to, 12 primary health care, 13–14t, 15, 207–8 E psychosocial interventions for adolescents, 190 early child development, 149–50, 192–93 self-care, 15 early intervention specialist health care delivery, 15 drug dependence of at-risk youth, 114 transcranial magnetic stimulation as treatment for psychosis treatment, 77 for, 74 East Asia and Pacific serotonin-norepinephrine reuptake inhibitors alcohol consumption in (SNRIs) and, 225 cost-effectiveness of interventions, 137, 221 suicide and, 69, 176 driver testing and arrest, 135 YLDs and, 68, 68f taxation, 133, 137 YLLs and, 49 cost-effectiveness of interventions in, 227t, 239 detoxification suicide prevention organizations in, 176 alcohol use disorders, 136, 137t, 139 suicide rates in, 164 substance abuse, 116, 120 traditional medicine in, 202 developed countries. See high-income countries (HICs) YLLs in, 44, 45–46f developing countries. See low- and middle-income Eastern Europe. See Central/Eastern Europe and countries (LMICs) Central Asia developmental disorders, children with. See childhood Eastern Mediterranean Region mental and developmental disorders suicide in, 170 developmental disorders, people with, 48. See also WHO proposed regional framework in, 23–24b childhood mental and developmental disorders eating disorders, 3, 32–34t diabetes, 41, 56, 128, 129, 184, 213 ECEA. See extended cost-effectiveness analysis 3 Dimensions of Care for Diabetes (UK), 213 economic effects Diagnostic and Statistical Manual of Mental Disorders of illicit drug dependence, 111 (DSM), 31 of mental, neurological, and substance use (MNS) DSM-4, 110, 208 disorders, 8 DSM-5, 71–72, 110 economic evaluation of treatment and prevention, 18b. disability-adjusted life years (DALYs) See also cost-effectiveness and affordability of alcohol use disorders and, 129 interventions caused by MNS disorders, 5, 30–35, 31f, 32t, 34t ECT (electroconvulsive therapy), 74 cost per DALY averted, 18, 19, 20f education and schools gender differences, 32–33, 32t, 34–33, 34f, 34t alcohol education campaigns, 139 illicit drug dependence and, 36, 111 early childhood enrichment programs, 192–93 disasters and refugees, 177 epilepsy education, 58 Disease Control Priorities in Developing Countries, 2b illicit drug dependence DisMod-MR, 43, 47, 49, 59 drug education, 114, 115t disruptive behavioral disorders. See attention-deficit skills training, 114, 115t hyperactivity disorder (ADHD); conduct mental health awareness, 73–74 disorders overdose prevention education, 114–15 domestic violence legislation, 186 peer-led education, 202 Dretzke, J., 155 preschool educational programs, 192–93 Index 271 school-based interventions, 189–92, 194 gender differences in, 5, 33 alcohol use, 19, 139 interventions for, 8, 10t, 89–93 childhood mental and developmental alternative therapies, 91 disorders, 150 anti-stigma interventions, 89–90 emergency response, 190, 191b helmet laws, 186 HealthWise program (South Africa), 190, 190b legislation, 90 identification and case detection, 190–91 management of infectious etiologies, 91 illicit drug dependence, 114, 115t optimizing health care delivery, 91–92 information and awareness, 189 pharmacological interventions, 58, 90–91 Mental Health First Aid for High School population platform interventions, 89 Teachers, 191 primary health care, 13–14t, 15 social and emotional learning interventions, self-management, 90, 203 189–90, 222, 229–30 surgical management, 91, 93 suicide and self-harm, 176 treatment gap, 58, 92f, 93b teacher training program, 191b mental illness and, 52 treatment, care, and rehabilitation, 192 recommendations for, 103 for vulnerable children, 190 status epilepticus, 88 whole-of-school approaches, 150 suicide and, 52 Egypt YLDs and, 90 childhood mental and developmental disorders, YLLs and, 43–45, 45f community-based interventions in, 149 Ethiopia suicide in, 170 alcohol use, demand reduction strategies for, 229 Eickmann, S. H., 149 cost-effectiveness of interventions in, 18b elderly persons. See also Alzheimer’s disease depression interventions in, 248t Home Care Program for (Goa), 207 productivity impact of scaled-up treatment, neurological disorders in, 36 246–47 suicide rates of, 164 extended cost-effectiveness analysis of publicly electroconvulsive therapy (ECT), 74 financed mental and neurological health care emergency response package in, 245–46, 247t drug-related interventions, 115 comparison with India, 249t humanitarian aid, 16 parenting skills training in, 152 mental health care, 204 school-based social and emotional learning school-based interventions, 190, 191b intervention in, 230 environmental events, 3b European Alliance against Depression Programme, 176 epilepsy, 88–93 European Headache Federation, 208 alcohol use disorders and, 49 evidence-based interventions for health care delivery, anti-epileptic drugs (AEDs), 88, 90, 91, 240 204, 205t autistic spectrum disorders and, 48 extended cost-effectiveness analysis (ECEA), 19, birth trauma and, 185 21f, 238 burden of disease, 30, 32–34t, 87, 88–89 application to MNS disorders, 238, 239 co-occurring disorders and, 52 comparison of India and Ethiopia, 249t cost-effectiveness of interventions for, 19, 20f, 58, Ethiopia analyses, 245–48 90, 93, 227t Indian analyses, 240–45 extended cost-effectiveness analysis, 241t principles and practice, 238 DALY ranking of, 90 deaths associated with, 7t, 41 F age of death, 53, 54t faith-based organizations, 202 definition of, 31, 88 family impacts and involvement, 1 epidemiology, 88–89 alcoholics, family-based interventions for, 135, 139 GBD findings of excess mortality for family history of suicide, 170 estimated number of cause-specific and excess illicit drug dependence, 110 deaths, 46t, 51–52, 51f in treatment, 74, 79 implications, 58 farmers, suicides of, 171 272 Index Farrington, D. P., 150 Global Health Estimates of disease burden, 5 fetal alcohol syndrome disorders (FASD), 128, 135, 139 globalization of alcohol beverages industry, 128 financial risk protection (FRP), 19, 203, 238, 239b Gmel, G., 133 Finland Good Behavior Game (US), 114 Alzheimer’s disease, pharmacological interventions good practice interventions, 12, 15, 183, 184t, 188, for, 98 193, 214 epilepsy-related deaths in, 52 Grading of Recommendations Assessment, illicit drug use in, 111 Development and Evaluation (GRADE) workplace treatment, care, and rehabilitation in, 189 guidelines, 8, 130–31 fluoxetine, 226 Gunnell, D., 17b folic acid deficiency, 94 H food fortification, 185 Handwerk, M., 155 forensic psychiatry, 203 Happell, B., 56 fragile X syndrome, 48–49 HCV (hepatitis C), 51, 57, 111, 119 France headache disorders, 99–102. See also migraine APPRAND program, 188 burden of disease, 100 fetal alcohol syndrome (FAS) warning labels in, 135 cost-effectiveness of interventions for, 102 FRP (financial risk protection), 19, 203, 238, 239b epidemiology, 100 Fuhr, D., 19 interventions for, 100–101, 188 alternative therapies, 101 G optimizing health care delivery, 102, 208 gatekeeper training, 176, 223 pharmacological interventions, 100–101 GBD. See Global Burden of Disease Study 2010 (GBD public education programs, 101–2 2010) self-management, 100 gender differences in burden of MNS disorders, 5, training health care providers, 102 32–34, 32t, 34f, 34t, 68 medication-overuse headache, 99–100 alcoholic consumption, 128–29 recommendations for, 103 childhood mental and developmental disorders, 5, tension-type headache, 99 33, 146, 147t Headache Management Trial, 208 illicit drug dependence, 5, 45, 46f health care platform interventions, 4b, 13–14t, 15–16, suicide and, 164, 165t, 166–67f 201–18 YLLs and, 45, 46f for alcohol use disorders, 135–37. See also alcohol generic drugs. See medications use disorders genotyping, 68 for childhood mental and developmental disorders, Global Burden of Disease Study 2010 (GBD 2010), 3, 151–54. See also childhood mental and 29–30. See also burden of MNS disorders developmental disorders comparative risk assessments. See comparative risk collaborative stepped care. See collaborative assessments (CRAs) stepped care excess mortality from MNS disorders, 41–65 for depression, 70 assessment as risk factors for other health elements of, 201–4 outcomes, 44. See also co-occurring disorders emergency mental health care, 204. See also cause-specific death estimates, 42, 44–53. See also emergency response specific MNS disorders evidence-based, 204 implications, 56–58 hospital level of care, 13–14t, 15, 203 methodology of study, 42–44. See also years of life for illicit drug dependence, 114–18, 116t. See also lost (YLLs) illicit drug dependence transition from communicable to integrating mental health into existing health noncommunicable diseases, 30, 36, 41 programs, 212–14 Global Burden of Disease Study 2013 (GBD 2013), 38 for mood and psychotic disorders, 74–78 Global Campaign against Headache, 101 primary level. See primary health care level Global Campaign against Headache for Europe, PRogramme for Improving Mental health carE 102, 208 (PRIME), 209, 231 Index 273 for psychiatric services, 203 illicit drug dependence, 109–25. See also amphetamine quality of care, 15, 214–15 dependence; cannabis dependence; cocaine relationships among difference delivery channels, 204 dependence; opioid dependence self-care and informal health care, 202–3. See also age of death attributable to, 54t self-care burden of disease, 32, 32–34t, 34, 111, 118 specialists. See also specialist health care delivery consequences, 110–11 training primary health care staff by, 210 consumption trends, 111 for suicide, 177–78 cost-effectiveness of interventions, 118, 120 system-strengthening strategies for, 204–9 criminal activity, 111, 119 task-sharing approach, 209–12, 210b DALYs associated with, 36, 111 Healthnet Transcultural Psychosocial Organization definition of, 31, 109–10, 120n1 (TPO), 17b delivery platforms for, 14t HealthWise program (South Africa), 190, 190b economic costs of, 111 hepatitis B, 51, 111 externalizing disorders, 114, 120n4 hepatitis C (HCV), 51, 57, 111, 119 family factors, 110 heroin. See illicit drug dependence; opioid dependence GBD findings of excess mortality for high-income countries (HICs). See also specific estimated number of cause-specific and excess countries deaths, 49, 50f, 51 alcoholic consumption in, 128, 138 implications of, 57–58 burden of MNS disorders in, 5, 29 gender differences in, 5, 45, 46f cost-effectiveness of interventions in, 19 global trends, 111 drug dependence treatments and implications for low- and middle-income countries, interventions, 118 118–19 dementia care costs in, 95f individual factors, 110 epilepsy-related deaths in, 51 injecting drug risks, 51, 53, 55t, 57, 226 intervention delivery platforms in, 12 internalizing disorders, 114, 120n4 screening children for developmental disorders, interventions and policies, 11t, 111–18 151–52 access to treatment, 114 specialist services, 2 brief psychological intervention, 115, 116t, 117 Hip Hop Stroke (awareness program for children), 189 cognitive behavioral therapy (CBT), 117 HIV/AIDS community-based care, 114–15, 116t alcohol use and, 184 community platform interventions, 113–14, 115t anti-epileptic drugs for people with, 91 contingency management approach, 117 burden of disease, 57 control of supply, 112 cost-effective prevention strategy, 226 court-mandated treatment, 112t, 113 dementia and, 94 criminal justice platforms, 113 illicit drug use and, 51, 58, 110–11, 115, 119 delivery platforms for, 14t integrating mental health into existing programs detoxification and withdrawal, 116, 120 for, 212 drug education, 114, 115t mental health needs of persons with, 213–14 drug testing of offenders, 112t, 113 methadone maintenance and, 117, 118 early intervention with at-risk youth, 114 suicide and, 169 health care platform interventions, 114–18, 116t HIV antiretroviral therapy, 57 imprisonment, 112t, 113, 120 home care programs, 207 law enforcement, 112, 112t, 119–20 Honduras, epilepsy treatment in, 89, 186 legislation, 186 hospital level of care, 13–14t, 15, 203 medication for cannabis dependence, 118 cost-effectiveness of, 228–29 medication for heroin and opioid dependence, humanitarian aid and emergency response, 16, 204 116t, 117 human rights violations, 58, 67, 214, 215 naloxone and other emergency responses, 115 overdose prevention education, 114–15 I population platform interventions, 112–13, 112t ibuprofen, 100 prescription monitoring programs, 112–13, 112t ICD-10. See International Classification of Diseases primary health care, 13–14t, 15, 115, 116t 274 Index psychosocial interventions, 117 maternal and infant health programs in, 153 public awareness campaigns, 112t, 113 National Sample Survey Organization, 238 residential rehabilitation, 117 pesticide ban in, 185 school-based prevention programs, 114, 115t school-based social and emotional learning self-help and mutual aid groups, 114, 115t intervention in, 230 skills training in schools, 114, 115t suicide in, 168, 170, 178 specialist health care delivery, 15, 116–17, 116t religious and spiritual beliefs, 172 supervised injecting facilities, 57, 115 safe storage of pesticides, 176 therapeutic community (TC) model, 117 universal health coverage, 240, 245f workplace drug testing, 113–14, 115t indigenous communities and alcohol consumption medical vs. moral models of addiction, 12, 119 community platform interventions, 135, 136t mortality rates, 110–11 prohibition, 131, 131t narcotic antagonists, 119, 120, 120n6. See also individual factors buprenorphine maintenance; naltrexone alcohol use disorders, 130 maintenance illicit drug dependence, 110 natural history of dependence, 110 infants novel psychoactive substances, 109, 120n2 immunization programs for, 185 peer group factors, 110 maternal and infant health programs, 153 pharmacotherapies, effectiveness of, 57–58 psychosocial interventions for, 149, 150 polydrug use, 114, 120n5 salt iodization programs for, 185 precursor chemicals, 112, 112t, 120n3 informal health care. See self-care recommendations, 119–20 information and communication packages, 78 research needs, 119, 120 injecting drug risks, 51, 53, 55t, 57, 226 risk factors, 110 Institute for Health Metrics and Evaluation at social and contextual factors, 110 University of Washington, 38 suicide and, 51, 55t, 110, 175 Institute of Medicine’s Forum on Neuroscience and YLLs and, 45f, 53, 110 Nervous System Disorders, 209 gender differences and, 45, 46f intellectual disability imprisonment for drug offenses, 112t, 113, 120 burden of disease, 32–34t India childhood, 145 alcohol consumption in, 129 defined, 145 demand reduction strategies for, 229 effective interventions for, 10t taxation on, 133 Inter-Agency Standing Committee’s Guidelines on unrecorded production and consumption, 221 Mental Health and Psychosocial Support in collaborative care for mental illnesses in, 77 Emergency Settings, 204 community-based rehabilitation in, 78 International Classification of Diseases (ICD-10), 5, 31, cost-effectiveness of interventions in, 18b 35, 37, 42, 46, 49, 72, 109, 168 depression, 230, 243–44, 244t International Convention on the Rights of Persons with extended analysis for schizophrenia, 19, 21f Disabilities, 186 Dementia Society of Goa, 207 International Labour Organization, 188 District Mental Health Programme, 208 International League against Epilepsy, 88 education and schools in interventions for MNS disorders, 8–12 examination stress, 175 for adult mental disorders, 73–78. See also adult teacher training for youth health promotion mental disorders program, 222 for alcohol use disorders, 130–37. See also alcohol teacher training to improve epilepsy use disorders knowledge, 191 case studies, 16–17b epilepsy interventions in, 240, 241t for childhood mental and developmental disorders, extended cost-effectiveness analysis (ECEA), 240–45 149–55. See also childhood mental and comparison with Ethiopia, 249t developmental disorders headache interventions in, 228b collaborative care models, 56 MANAS (MANashanti Sudhar Shodh, or project to community-based. See community platform promote mental health), 78, 207, 224–25 interventions Index 275 costs. See cost-effectiveness and affordability of traditional medicine in, 202 interventions YLLs in, 44, 45–46f delivery platforms of, 12–17, 13–14t law enforcement for dementia, 96–98 alcohol use disorders and, 132t effective essential interventions, 8–12, 9–11t illicit drug dependence and, 112, 112t, 119–20 health care. See health care platform interventions legislation for illicit drug dependence, 11t, 111–18. See also on alcoholic beverages, 221–22 illicit drug dependence child protection legislation, 148–49 limited access to, 12 on epilepsy, 90 population-based. See population platform illicit drugs legislation, 186 interventions mental health legislation, 73 quality of care, 15, 214–15 restricting access to lethal means of suicide, 17b, iodine deficiency, 185 176, 185, 194, 222 Iran, suicide in, 176, 177 licensing of alcoholic beverages sellers, 138 Israel life expectancy gap in people with mental disorders, 41, community-based interventions for childhood 42, 57. See also years of life lost (YLLs) mental and developmental disorders, 149 lifestyle risk factors, 47, 56–57, 58, 101 Heart Disease study, 52 Lim, S. S., 44, 129 List of Essential Medicines (WHO), 57 J liver cirrhosis, 50, 184 Jamaica low- and middle-income countries (LMICs). See also childhood emotional and behavioral problems specific countries in, 150 alcohol consumption in, 128 psychosocial interventions for malnourished infants challenges for, 138–39 in, 149, 150 cost-effective interventions, 221 mortality rates associated with, 130 K recommendations for, 139 Kamgno, J., 52 burden of MNS disorders in, 29 Kenya cause-of-death data from, 58 epilepsy-related deaths in, 52, 88 childhood mental and developmental disorders, epilepsy treatment in, 89 community-based interventions in, 149 training of primary care workers in, 210 dementia care costs in, 95f ketogenic diet, 91 epilepsy-related deaths in, 51 key messages, 4b epilepsy treatment gap in, 58, 92f Kilian, R., 155 illegal substance dependence in knowledge gaps, effect on scaling up, 21–22 assessment issues, 118 Korea, Republic of burden of disease, 118 dementia detection program in, 98 cost-effectiveness of interventions, 118 suicide in, 175 health care infrastructure and capacity, 119 implications, 118–19 L medical vs. moral models of addiction, 119 Lachenmeier, D., 133–34 opioid substitution treatment (OST), 57, 119 Latin America and the Caribbean potential new treatments, 119 alcohol consumption in, 129 research needs, 119 cost-effectiveness of interventions, 137, 221 intervention delivery platforms in, 12, 29 partial bans on, 132 MNS disorders in, 5 self-help and support groups, 136, 137 mood and anxiety disorders in, 69 taxation on, 132–33 neurological disorders in, 87 cost-effectiveness of interventions in, 221, 226, 227t suicide surveillance in, 168 substance use disorders in, 44 survey of mental disorders in, 38 suicide in transition from communicable to religious and spiritual beliefs, 172 noncommunicable diseases in, 41 risk factors, 169 vital registration systems, lack of, 163 survivors of suicide loss, 172 lung cancer, 42 276 Index M mortality rates associated with, 6. See also mortality major depressive disorder. See depression rates Malaysia, suicide in, 175, 177 need for action to address, 22–23 MANAS (MANashanti Sudhar Shodh, mental health significance for global health, 5–8 project in India), 78, 207, 224–25 substance abuse. See illicit drug dependence mania, 69, 71. See also bipolar disorder years lived with disability (YLDs) and, 5, 6f. See also mass media campaigns. See public awareness years lived with disability campaigns years of life lost (YLLs) and, 5, 6, 6f. See also years of maternal depression. See postpartum depression life lost maternal mental health interventions, 152–53, 212 mental disorders. See adult mental disorders; childhood Mauritius mental and developmental disorders; mental, preschool program in, 150 neurological, and substance use (MNS) disorders; school-based prevention program for adolescent specific disorders (e.g., anxiety, depression) depression in, 222, 229 mental health awareness campaigns, 73, 186–87. See school-based social and emotional learning also public awareness campaigns intervention in, 230 mental health first aid training, 188, 191, 193, 223 Maximizing Independence at Home project, 97 Mental Health Gap Action Programme (mhGAP). media reporting of suicide and self-harm, 175 See World Health Organization (WHO) medical marijuana, 91 mental health legislation, 73. See also legislation medical vs. moral models of addiction, 12, 119 mental health workers medications health centers or home visitation programs access of people with mental disorders to, 48 using, 193 for ADHD, 154 human resource competencies for MNS disorders antipsychotics for dementia patients, 53, 96–97 in, 210 for conduct disorder, 154 low availability of, 12 cost-effectiveness of, 226 pre-service and in-service training of primary care for epilepsy. See anti-epileptic drugs (AEDs) workers, 210 low-cost generics, 22, 226 methadone maintenance, 57, 111, 113, 117, 118, 226 morbidity and mortality rates related to treatment Mexico with, 47 alcoholic beverages in pharmacotherapies cost-effectiveness of interventions, 138 for dementia, 96–97, 98 demand reduction strategies for, 229 for epilepsy, 90–91 unrecorded production of, 133 for headache disorders, 100–101 illicit substance use in, 111 for heroin and opioid dependence, 116t, 117 school-based social and emotional learning for mood and psychotic disorders, 74, 75–76t, 79 intervention in, 230 for substance use disorders, 48, 57–58, 118 mhGAP. See World Health Organization prescription monitoring programs, 112–13, 112t microfinance, 193 psychotropic medications Middle East and North Africa effects of, 48, 56 cost-effectiveness of interventions in, 227t primary care staff prescribing, 212 illicit drug dependence in, 44 Megiddo, I., 240 suicide of women in, 171 memantine, 96, 98 midwives, role of, 212 men. See gender differences migraine. See also headache disorders mental, neurological, and substance use (MNS) burden of disease, 32–34t, 87 disorders, 1, 2. See also neurological disorders; cost-effectiveness of interventions for, 228b specific types of disorders DALYs associated with, 36 adults. See adult mental disorders deaths associated with, 7t alcohol abuse. See alcohol use disorders definition of, 99 children. See childhood mental and developmental estimated number of cause-specific and excess disorders deaths for, 46t disability-adjusted life years (DALYs) due to, 5. See interventions for, 10t, 188 also disability-adjusted life years primary health care, 13–14t, 15 economic output lost due to, 8 self-care, 15 Index 277 Mihalopoulos, C., 155, 223 YLDs and, 87 Millennium Development Goals, 214 YLLs and Mini-Mental State Examination, 96 gender differences and, 45, 46f MNS. See mental, neurological, and substance use regional differences and, 55 (MNS) disorders New Zealand monitoring and evaluation of interventions, 22 fetal alcohol syndrome (FAS) warning labels in, 135 monitoring and reporting systems indigenous communities, alcohol consumption by, 135 dementia, 213 Nigeria suicide and self-harm, 177 alcohol use, demand reduction strategies for, 229 mood disorders, 68–70, 75t. See also anxiety disorders; community-based awareness in, 73 depression depression in, 69, 70, 208, 225 moral vs. medical model of addiction, 12, 119 epilepsy in, 230 morphine maintenance, 117 schizophrenia in, 225, 230 mortality rates. See also Global Burden of suicide in, 169 Disease Study 2010 (GBD 2010); years of life noncommunicable diseases lost (YLLs) compared to communicable diseases in global for alcohol use disorders, 7t, 44, 129 burden of disease, 30, 36, 41 cause-of-death data, difficulty in capturing, 58–59 integrating mental health into primary care for, 213 illicit drug dependence, 110–11 nonspecialist human resource cadres, 15, 22 MNS disorders associated with, 6–7, 7t, 22, 41 Norwegian dementia mortality study, 52 models used in estimating, 43, 43f novel psychoactive substances, 109, 120n2 suicide mortality rates, 164, 165t multiple sclerosis, 3, 29, 32–34t, 87 O multisystem therapy, 155 obesity, 49, 56–57, 100 music therapy, 74 obsessive-compulsive disorder (OCD), 70 mutual aid groups. See support groups occupational therapy, 76, 79 Open the Doors program, 187 N opioid dependence. See also illicit drug dependence naloxone and other emergency responses, 115 burden of disease, 32–34t naltrexone maintenance, 57, 117, 119 consumption trends, 111 narcotics. See illicit drug dependence DALYs associated with, 36 National Institute for Health and Care Excellence deaths associated with, 7t, 37, 41 (NICE), 99 age of death, 54t natural history models, 43, 45–46, 48, 49, 59 GBD findings of excess mortality for needle programs, 57 estimated number of cause-specific and excess neighborhood factors, 3b deaths, 46t, 50f, 51 neighborhood groups, 192–93, 194. See also self-help implications, 57–58 programs; support groups illicit opioids, 109 neurocysticercosis, 89b, 91, 186 naltrexone maintenance, 117 neurological disorders, 87–108. See also epilepsy; opioid substitution treatment (OST), 57, 113, headache disorders 114, 118, 119, 120. See also methadone burden of disease, 30, 32–34t, 87 maintenance community health workers’ detection abilities, 193 prevalence in Australasia and Western Europe, 37 cost-effectiveness of interventions for, 226 rates of dependence, 110 in elderly persons, 36 substance use disorders and, 51 GBD findings of excess mortality for supervised injectable heroin maintenance, 57, 117 estimated number of cause-specific and excess YLLs and, 37, 43 deaths, 46t, 51, 51f overdose prevention education, 114–15 implications, 58 oxycodone, 111. See also opioid dependence gender differences in, 45, 46f interventions for, 10t P delivery platforms, 14t Pakistan school-based interventions, 189, 192 depressive disorder related to suicide in, 169 278 Index mental health awareness among school post-traumatic stress disorder (PTSD), 49, 68, 70, 75t, children in, 74 77, 192 preventive maternal and child health care in, 153 poverty. See also financial risk protection (FRP) rural secondary schools in, 189 microfinance schemes and, 193, 221 suicide in, 175 schizophrenia and, 48 depressive disorder related to, 169 suicide and, 169, 170, 175 women, 171 Powell, C., 149 Thinking Healthy Programme, 212 precursor chemicals, 112, 112t, 120n3 Palestine, school-based intervention in, 191b pregnancy panic disorder, 70, 75t alcohol use in, 135, 139 parenting interventions, 193 vulnerability for MNS disorders, 185 community-based program for, cost-effectiveness premature mortality, 5. See also years of life of, 222–23 lost (YLLs) skills training, 152, 213–14 Preventing Suicide: A Global Imperative (WHO), 177 Parkinson’s disease prevention of MNS disorders, 4b, 8–12, 9–11t. See also burden of disease, 30, 32–34t, 87 interventions for MNS disorders gender differences in, 5, 33 adult mental disorders, 76–77 peer-led interventions cost-effectiveness of. See cost-effectiveness and education, 202 affordability of interventions illicit drug dependence, 110 primary health care level, 13–14t, 15, 203 self-help groups and peer support, 203 for alcohol use disorders, 13–14t, 15 Perinatal Mental Health Project (South Africa), 212 competency-based education, 209–10, 209t pesticides cost-effectiveness of, 224–27 regulation to restrict access to, 17b, 176, 185 international studies, 226 safe storage of, 176 national studies, 224–26 self-poisoning, 175, 177 evidence-based, 205t Phanthunane, P., T. Vos, 225 for illicit drug dependence, 13–14t, 15, 115 pharmacologic treatment. See medications planning and consultation, 210 phobias, 70 pre-service and in-service training of Pion, S. D. S., 52 workers, 210 Plan Do Study Act, 214 psychotropic medications, prescription authority Platania-Phung, C., 56 for, 212 pneumonia, 53, 56 Prince, M., 44 political will, effect on scaling up, 21 problem-solving skills therapy (PSST), 155 polydrug use, 114, 120n5 PRogramme for Improving Mental health carE Pompili, P., 52 (PRIME), 209, 231 population platform interventions, 13–14t, 15, 183–87, psychiatric services, 203. See also specialist health 193–94 care delivery for adult mental health, 73 psychosis, 2 for alcohol use disorders, 130, 131–35, 131t extended cost-effectiveness analysis for, 19 for childhood mental and developmental disorders, interventions for, 8 148–49 medications for, 226 for epilepsy, 89 primary health care for, 13–14t, 15 for illicit drug dependence, 112–13, 112t specialist health care delivery for, 15 information and awareness campaigns, 186–87 psychosocial interventions key findings, 183 for conduct disorder, 154–55 legislation and regulations, 184–85. See also for illicit drug dependence, 117 legislation for malnourished infants, 149 protecting persons with MNS disorders, 186 psychosocial life crises and suicide, 169–70 restricting access to means of suicide, 185 psychotherapy for mood and psychotic disorders, 74, for suicide, 174–75 75–76t postpartum depression, 75t, 77, 152–53, 212 psychotropic medications, effects of, 48, 56 women’s support groups for, 153 PTSD. See post-traumatic stress disorder Index 279 public awareness campaigns, 186–87, 194 extended cost-effectiveness analysis for, 19, 21f alcohol consumption, 135 health system barriers and opportunities for, 21–22 headaches, 101, 102 knowledge gaps as factors, 21–22 illicit drug dependence, 112t, 113 political will as factor, 21 mental health, 73 proposed regional framework in WHO Eastern Public Health Action for the Prevention of Suicide Mediterranean Region, 23–24b (WHO), 177 strategies for strengthening health system, 22 public health considerations schizophrenia, 72–73 alcohol use disorders, 128 age of cause-specific and excess deaths attributed health platform related, 208 to, 47f integrating mental health into existing programs, 212–14 burden of disease, 32–34t maternal mental health, 153 cannabis dependence and, 53, 55t suicide, 173 clinical features and course, 72 co-occurring disorders with, 48 Q cost-effectiveness of interventions for, 19, 20–21f, quality-adjusted life years (QALYs), 155, 225 225, 227t, 230 quality of care, 15, 214–15. See also health care platform community-based vs. hospital-based interventions services, 228 extended cost-effectiveness analysis, 242t R DALYs associated with, 36 RAP-A program, 230, 230t deaths associated with, 7t refugees, suicides of, 171–72, 177 age of death, 54t rehabilitation environmental factors associated with, 68 cognitive rehabilitation for dementia, 97 epidemiology and burden of disease, 72–73 illicit drug dependence, 117 estimated number of cause-specific and excess mental disorders, 78 deaths for, 46–48, 46t, 47f Rehm, J., 133–34, 137, 221 extended cost-effectiveness analysis for, 19, 21f, relaxation techniques, 74 241–45 religious beliefs and suicide, 172 gender differences in, 5, 33, 68 religious healers, 202 genotyping of individuals with, 68 research and development initiatives, 22 interventions for. See also adult mental disorders for illicit drug dependence, 119, 120 enhanced financial and service coverage, 241–43 residential facilities, 15–16, 203 pharmacologic and psychological treatment, 76t for illicit drug dependence interventions, 117 side effects of antipsychotic medications for, 48 Resourceful Adolescent Programme-Adolescent version suicide and self-harm and, 48 (RAP-A) program, 229–30, 230t YLDs and, 68, 68f respiratory diseases, 41, 56 YLLs and, 43, 45f, 48 risk factors schools. See education and schools for childhood mental and developmental disorders, Scott, D., 56 146–48, 148t screenings for illicit drug dependence, 110 for alcohol use disorders, 135–36, 136t, 139 for suicide, 37, 168–71, 173f, 178 for childhood mental and developmental disorders, risperidone, 226 151–52, 156 Russian Federation, headache interventions in, 102, for comorbid health issues, 56–57 208, 228b for dementia, 98 for illicit drug dependence, 115, 117 S for mental health disorders, 77 Saxena, S., 232 SDG (sustainable development goal), 2b scaling up, 4–5b self-care, 13–14t, 15, 202–3 affordability and. See cost-effectiveness and for epilepsy, 90 affordability of interventions evidence-based, 205t case studies of interventions for MNS disorders, for headache disorders, 100 16–17b for mood and psychotic disorders, 74 280 Index self-harm. See suicide and self-harm specialist health care delivery, 15, 74–76, 203 self-help programs, 57, 202–3 for alcohol use disorders, 15 for alcohol use disorders, 136–37 for childhood mental and developmental for illicit drug dependence, 114, 115t disorders, 154–55 self-immolation. See suicide and self-harm cost-effectiveness of, 228–29 serotonin-norepinephrine reuptake inhibitors evidence-based, 205t (SNRIs), 225 for extended-stay facilities, 203 Service Organization Pyramid for an Optimal for illicit drug dependence, 15, 116–17, 116t Mix of Services for Mental Health (WHO), Sri Lanka 202, 202f children with developmental delays in, 151 sexual minorities, suicide of, 172 suicide in, 170, 171, 175, 177–78 shame and fear, 67 prevention through pesticide regulation, SHR (sustained headache relief), 100 17b, 185, 185b simple phobias, 70 safe storage of pesticides, 176 Single Convention on Narcotic Drugs, 120n1 START (STrAtegies for RelaTives) study, 99 Six Sigma, 214 Statistical Process Control, 214 Skeen, S., 194 stigma and discrimination, 1, 5b, 22, 67 smoking, 47–48, 49, 52, 56–57 anti-stigma interventions, 89–90, 187 Sneha (suicide prevention organization), 175 limiting access to interventions, 12 sobriety checkpoints, 134 limiting access to screenings, 56 social anxiety disorder, 70 quality of care and, 214 social causation pathway, 3b self-care and, 203 social change, 3b suicide and, 175, 176 social determinants, 1, 3b Strang, J., 8 for illicit drug dependence, 110 stroke, 41, 56 social drift pathway, 3b Sub-Saharan Africa societal response to alcohol use disorders, 130 alcohol consumption in, 129 socioeconomic status, 3b. See also poverty cost-effectiveness of interventions, 137, 221 drinking and, 129 mortality associated with, 129 schizophrenia and, 48 taxation, 133, 137 SOLVE training package, 188 childhood mental disabilities, lack of data on, 146 Sornpaisarn, B., 133 cost-effectiveness of interventions in, 221, 226, 227t, South Africa 231, 239 alcohol consumption of pregnant women in, 135 epilepsy in, 44, 45, 52, 89, 91 collaborative stepped care approach in, 210 human resource competencies for MNS disorders epilepsy treatment in, 89 in, 210 HealthWise program in, 190, 190b illicit drug dependence in, 44 HIV/AIDS treatment integrated with mental cost-effectiveness of interventions, 118 health in, 214 microfinance in, 193 parenting skills training in, 152 traditional medicine in, 202 Perinatal Mental Health Project, 212 YLL rates in, 44, 45–46f, 55 Primary Care 101 (PC101), 214 gender differences and, 45, 46f primary care practitioners in, 208 substance use disorders. See illicit drug dependence workplace interventions in, 189 suicide and self-harm, 42, 163–81 South Asia of adolescents, 171 alcohol consumption in age pattern of, 164, 165t, 166–67f cost-effectiveness of interventions, 137, 221 alcohol consumption and, 50, 129, 169, 175 taxation, 133, 137 as cause of death, 41, 164 cost-effectiveness of interventions in, 226, 227t, changes in rates (2000-12), 164, 165t 231, 239 coping strategies and well-being, 172 suicide prevention organizations in, 176 cost-effectiveness of prevention efforts, 178 suicide rates in, 164 decriminalization of, 175 traditional medicine in, 202 definition of, 163 Index 281 depression and, 69, 176 suicide mortality rates, 164, 165t drug misuse and, 175 surveillance in LMICs, 168 early traumatic events associated with, 170–71 survivors of suicide loss, 172 economic issues and, 175 urban vs. rural locations, 170 effective interventions for, 11t WHO prevention guidelines, 57, 163, 173 epidemiology, 163 YLLs and, 53, 55 epilepsy and, 52 supervised injecting facilities, 57, 115 exposure to models, 170 support groups, 192–93, 194. See also self-help family history of suicide, 170 programs of farmers, 171 for alcohol use disorders, 136–37 gender differences, 164, 165t, 166–67f, 171 for illicit drug dependence, 114, 115t interventions for, 11t, 174–78 suspension of driver’s license, 135 brief intervention and contact, 177 sustainable development goal (SDG), 2b community platform interventions, 175–76 sustained headache relief (SHR), 100 delivery platforms, 14t Sweden disasters and refugees, 177 cost of Alzheimer’s disease treatment in, 98 examination stress, 175 dementia-related deaths in, 53 gatekeeper training, 176 epilepsy-related deaths in, 52 health care platform interventions, 177–78 Szekely, A., 176 medical management of poisoning with pesticides, 177 T monitoring and reporting systems, 177 Tanzania national suicide prevention strategies, 177–78 epilepsy-related deaths in, 52 nongovernmental organization services, 175–76 epilepsy treatment in, 89 population platform interventions, 174–75, 194 task-sharing approach, 209–12, 210b restricting access to lethal means, 17b, 174–75, taxation of alcoholic beverages, 131t, 132–33, 138, 176, 185, 194, 222 221, 229 safe storage of pesticides, 176 Taylor, B. J., 133–34 school-based interventions, 176 teacher training program to identify and assess mental stigma and discrimination, 175 health problems, 191, 191b media reporting of, 175 TEAMcare USA and TEAMcare Canada, 213 mental disorders and alcohol misuse associated telemedicine, 78 with, 169 Ten Questions screen, 151, 151b methods, availability of, 168, 170 testing pesticide self-poisoning, 175, 177 blood alcohol concentration (BAC) testing of Sri Lanka suicide prevention through pesticide drivers, 134 regulation, 17b, 185b breath testing of drivers, 134 physical disorders and, 169 Thailand prevention in LMICs, 172–74 alcoholic beverages, regulation of, 128 prior suicide attempts, 170 antidepressants and CBT as cost-effective protective factors, 172 interventions for depression in, 225 psychosocial life crises and, 169–70 therapeutic community (TC) model, 117 as public health issue, 173 Thinking Healthy Programme (Pakistan), 212 of refugees and internally displaced persons, 3 Dimensions of Care for Diabetes (UK), 213 171–72, 177 Total Quality Management, 214 religious and spiritual beliefs, 172 TPO (Healthnet Transcultural Psychosocial risk factors for, 37, 168–71, 173f, 178 Organization), 17b schizophrenia and, 48 traditional healers, 202 of sexual minorities, 172 traffic accidents. See driving impaired and traffic stigma of, 176 accidents strong personal relationships and, 172 transcranial magnetic stimulation, 74 substance use disorders and, 51, 55t, 110 traumatic brain injury, measures to protect suicide attempt rates, 164–68 against, 186 282 Index treatment gap, 214 unrecorded market of alcohol production and sales, in epilepsy, 58, 92f 133, 138–39 treatment of MNS disorders, 4b, 8–12, 9–11t. See also urinary tract infections, 53 interventions for MNS disorders cost-effectiveness of. See cost-effectiveness and V affordability of interventions vicious cycle of social determinants, 3b Ttofi, M. M., 150 violence tuberculosis, 50, 129, 212, 213–14 alcohol-attributable, 50, 129 Turkey domestic violence legislation, 186 early childhood enrichment project in, 192 Vreeman, R. C., 150 suicide in, 170, 171 W U warning labels on alcoholic beverages, 135, 139 Uganda web-based psychological therapy, 15, 78 epilepsy treatment in, 89 Whiteford, H. A., 31 specialists training primary health care WHO. See World Health Organization staff in, 210 whole-of-government approach, 205 United Kingdom whole-of-school approach, 150 Alzheimer’s disease, pharmacological interventions women. See also gender differences; pregnancy for, 98 gender equity and economic empowerment bipolar disorder research in, 48 interventions, 193 cognitive rehabilitation for dementia in, 97 postnatal depression. See postpartum depression community-based awareness in, 73 suicide rates of, 171 community-based vs. hospital-based programs workplace interventions, 194 in, 73 drug testing, 113–14, 115t coping strategy program for mental health of epilepsy, anti-stigma interventions for, 89 dementia caregivers in, 225 identification and case detection, 188 crisis intervention teams in, 77 mood and anxiety disorders intervention, 73 epilepsy-related deaths in, 52 promotion and primary prevention, 188 parenting programs in, 223 World Development Report (1993), 2b 3 Dimensions of Care for Diabetes, 213 World Health Organization (WHO) United Nations Assessment Instrument for Mental Health Systems Children’s Fund Multiple Indicator Cluster (WHO-AIMS) survey, 73 Survey, 151 Atlas on Substance Use, 137 Convention on the Rights of Persons with Building Back Better, 204 Disabilities, 215 Child and Adolescent Mental Health Policies and United States Plans, 148 court-mandated drug treatment in, 113 CHOosing Interventions that are Cost-Effective depression in, 69 (CHOICE) project, 220, 226, 228, 228b, 232 Drug Abuse Resistance Education (DARE) Comprehensive Mental Health Action Plan, 22, 24 program, 114 cost-effectiveness analysis, 18 fetal alcohol syndrome (FAS) warning labels in, 135 detection of mental disorders, system for, 77 Good Behavior Game for classroom behavior Global Health Estimates, 5, 163, 166f management with young children, 114 High-Level Meeting on Non-communicable stroke awareness program for children in, 189 Diseases (2011), 229 TEAMcare USA, 213 Integrated Management of Adult and Adolescent universal health coverage, 5b, 18b, 19, 237–51. See also Illness (IMAI), 213 extended cost-effectiveness analysis (ECEA) List of Essential Medicines, 57 health system goals, 237 Mental Health Gap Action Programme (mhGAP), 1, MNS coverage, 237–38 5, 8, 17b, 22, 74, 77, 204, 245 pay out-of-pocket (OOP) for treatment, 237–38 alcohol consumption and, 135, 136 University of Washington’s Institute for Health Metrics depression and, 208 and Evaluation, 38 Mental Health Global Action Program, 177 Index 283 Ministerial Conference on Global Action Against population attributable fractions (PAFs) and, 44 Dementia (2015), 99 schizophrenia, 68, 68f noncommunicable disease interventions years of life lost (YLLs), 5, 6, 6f, 30–31, 35, 35f, 37, 41 package, 213 alcohol use disorders, 43–45, 45f, 53, 55, 55t Preventing Suicide: A Global Imperative, 177 amphetamine dependence, 43 proposed regional framework in Eastern attributions needed for more accurate Mediterranean Region, 23–24b representation of MNS disorders, 55 Public Health Action for the Prevention of cause of death and, 42–43, 46, 53–55 Suicide, 177 cocaine dependence, 43 on quality improvement (QI) mechanisms, 214 dementia, 43, 45f QualityRights Project, 186 depression, 49 QualityRights Toolkit, 215 differences in patterns of MNS prevalence and, recommended method for integrating hospital- 44–45, 45f based and community-based mental health gender differences, 45, 46f services, 16b illicit drug dependence, 45f, 53, 110 Service Organization Pyramid for an Optimal Mix of gender differences and, 45, 46f Services for Mental Health, 202, 202f natural history models and, 45–46 on suicide and suicide prevention, 57, 163, 173, 177, neurological disorders 178 gender differences and, 45, 46f World Mental Health Action Plan (2013-2020), 177 regional differences and, 55 World Mental Health (WMH) surveys, 69–70, 71, opioid dependence, 37, 43 102, 166 population attributable fractions (PAFs) and, 44 YLDs assigned to MNS disorders, 30 regional differences and, 53–54, 55f World Psychiatric Association, 187 schizophrenia, 43, 45f, 48 suicide and, 53, 55 Y years lived with disability (YLDs), 5, 6f, 30–31, Z 35, 35f, 37 Zambia adult mental disorders, 67–68, 68f epilepsy treatment in, 90 epilepsy, 90 headache disorders and treatment in, 100, from natural history models, 43 102, 228b neurological disorders, 87 trauma-focused CBT for children in, 154 284 Index ECO-AUDIT Environmental Benefits Statement The World Bank Group is committed to reducing its environmental footprint. 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