Global Mental Health

Improving Care for Depression

Jürgen Unützer, MD, MPH, MAApril 1, 2011

Jürgen Unützer, MD, MPH, MAProfessor, Psychiatry & Behavioral SciencesAdjunct Professor, Health ServicesDirector, AIMS Center

• Grant funding – NIH (NIMH)– AHRQ– John A. Hartford Foundation – American Federation for Aging Research (AFAR)– Alaska Mental Health Trust Authority– George Foundation– California HealthCare Foundation– Robert Wood Johnson Foundation– Hogg Foundation for Mental Health

• Contracts– Community Health Plan of Washington– Public Health of Seattle & King County

• Consultant– AARP Services Incorporated (ASI)– National Council of Community Behavioral Health Care (NCCBH)

• Advisor– Carter Center Mental Health Program– Institute for Clinical Systems Improvement (ICSI)– World Health Organization (WHO)

updated February 2011

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

http://uwaims.org

University of Washington

Mental Disorders are Rarelythe Only Health Problem

Mental Health / Substance Abuse

NeurologicDisorders

10-20%

Diabetes

10-30%

Heart Disease

10-30%

Chronic Physical Pain

25-50%

Cancer

10-20%

Smoking, Obesity, Physical Inactivity

40-70%

Improving Care for Depression

Common10% in primary care, more common inpatients with chronic medical illnesses

Disabling #2 cause of disability (WHO)

Deadly Over 30,000 suicides / year

Expensive 50-100% higher health care costs(ED, inpatient, outpatient, pharmacy)

IMPACT Team Care Model

EffectiveCollaboration

PCP supported by Behavioral Health

Care Manager

Informed, Active PatientPractice Support

Measurement Caseload-focused psychiatric consultation

Training

IMPACT Doubles the Effectiveness of Depression Care

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8

Usual Care IMPACT

%

Participating Organizations

50 % or greater improvement in depression at 12 months

42%43%

54%

14%

23%19%

0%

10%

20%

30%

40%

50%

60%

White Black Latino

IMPACT Care

Care as Usual

IMPACT Care BenefitsEthnic Minority Populations

Areán et al. Medical Care, 2005

50 % or greater improvement in depression at 12 months

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

Global Mental Health• Refugee / Migrant Health• Mental Health (WHO)

– Senior Advisor, Depression Initiative & World Health Report (2000-2001)

– Member; mhGAP Guideline Development Group (2009-2010)

• Consultant on Initiatives to Improve Depression Care in – Africa and Latin America

WHO Definition of Health

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

Health DisparitiesExample from World Health Report 2001

Afghanistan US

Population 21.7 million 283 million

Annual Growth 4.8 % 1.1 %

Population over 65 4.7 % 16.1 %

Fertility Rate 7.0 2.0

Probability of Dying Under age 5

25 % 0.9 %

Life Expectancy 44.6 years 76.3 years

Healthy Life Expectancy

33.8 years 67.2 years

Injuries (9.1%)

Noncommunicableconditions (59.8%)

Death, by broad cause groupin 1999

Communicable diseases, maternal and perinatal

conditions and nutritional deficiencies (31.1%)

Neuropsychiatric Disorders account for 1.7 % of deaths.

Global Burden of Disease• Harvard School of Public Health , World Health Organization,

World Bank – 1993• A ‘health gap’ measure: incorporates losses of ‘healthy life’

due to premature death and disability. • 1 DALY = 1 year of ‘healthy life lost due to death or disability.• References

– World Bank (1993): World Development Report. NY, Oxford University Press.

– Murray CJL, Lopez A (eds)( 1996): The Global Burden of Disease. Harvard School of Public Health.

– Murray CJL, Lopez A (2000): Progress and directions in refining the global burden of disease approach. Health Economics 9: 69-82.

Injuries (13.9%)

Noncommunicableconditions (43.2%)

Global burden of diseasein disability-adjusted life years (DALYs)

in 1999

Communicable diseases, maternal and perinatal

conditions and nutritional deficiencies (42.8%)

Neuropsychiatric Disorders account for 12.3 % of DALYs.

30

40

50

60

70

80

90

1950-55 1970-75 1990-95 2010-15 2030-35

Ye

ars

Africa Asia Europe Latin America and Caribbean Northern America

Increasing Life Expectancy at Birth: focus on noncommunicable diseases

Fig 3: UN, The Population Prospects, 1998 up-date

1999 Disease or Injury 2020 Disease or Injury

Increasing Burden of Noncommunicable Diseases and InjuriesChange in rank order of DALYs for the 15 leading causes

DALY = Disability-adjusted life year

1. Acute lower respiratory infections2. HIV/AIDS3. Perinatal conditions4. Diarrhoeal diseases5. Unipolar major depression6. Ischaemic heart disease7. Cerebrovascular disease8. Malaria9. Road traffic injuries10. Chronic obstructive pulmonary disease11. Congenital anomalies12. Tuberculosis13. Falls 14. Measles15. Anaemias

1. Ischaemic heart disease2. Unipolar major depression3. Road traffic injuries4. Cerebrovascular disease5. Chronic obstructive pulmonary disease6. Lower respiratory infections7. Tuberculosis8. War9. Diarrhoeal diseases10. HIV11. Perinatal conditions12. Violence 13. Congenital anomalies14. Self-inflicted injuries15. Trachea, bronchus and lung cancers

Source: WHO, Evidence, Information and Policy, 2000

“An estimated 400 million people alive today suffer from mental or neurological disorders or from psychosocial problems related to alcohol and drug abuse.

Dr Gro Harlem Brundtland, Director General WHO Geneva, 12 February 2001

Our advocacy effort will concentrate on reducing stigma associated with mental ill health and neurological disorders and on raising awareness about the many effective, affordable treatments that are available but underused, both in developing and industrialized countries.”

Many of them suffer silently and alone. Beyond the suffering and beyond the absence of care lie the frontiers of stigma, shame, exclusion and, more often than we care to know, death.

STOP EXCLUSION

DARE TO CARE

Santé mentale:Non à l’exclusion, oui aux soins

Mental Health:Stop exclusion – Dare to care

Охрана психического здоровья:

откажитесь от изоляции - окажите помощь Salud mental:Sí a la atención, no a la exclusión

Global School Contest

To raise awareness among youth by addressing issues of stigma and mental health;

Three categories: 6-9 years (drawing); 10-14 years (essay, 250 words); 15-18 years (essay, 500 words);

Public and private schools worldwide;

Winners (1 per category) announced on 7 April (countries/regions); 3 global winners honoured at the WHO World Health Assembly in May, 2001.

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

                                                                                                                                                                                                    

• Released October 4, 2001

• http://www.who.int/whr

World Health Report 2001

Messages (1-3)

Mental health is relevant to all of health.

Mental disorders are real, diagnosable, common and universal. If left untreated, they can produce suffering and severe disability in individuals, and major social and economic losses.

Mental disorders are treatable. Prevention and treatment are possible and feasible, but currently most sufferers are unreached.

Recommendations1. Provide treatment in primary care

2. Make psychotropic medications available

3. Give care in the community

4. Educate the public

5. Involve communities, families, and consumers

6. Establish national policies, programs, and legislation

7. Develop Human resources

8. Link with other sectors

9. Monitor community mental health

10. Support more research.

World Health Report 2001

                                                         

                                                

Psychiatric beds per 10,000 population

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

                                                           

                                              

                                                           

                                              

Clinical psychologists per 100,000 population

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

Depressive disorders

What are they?depressed mood, loss of interest and pleasure; symptom severity and duration differentiate them from normal mood changes;bipolar disorders: depression alternates with mania (exaggerated elation or irritability)

How many suffer?3 – 10 % of adults

What can be done?antidepressant medications; psychosocial interventions (e.g behavioral activation, cognitive-behavior therapy, problem solving treatment, interpersonal therapy).

ICD-10 Depression• At least two of three core symptoms

– Low sad or mood– Loss of interest or pleasure in daily activities– Lack of energy or increased fatiguability

• And at least two of the remaining symptoms– Disturbed sleep– Disturbed appetite– Restlessness or slowing of movements or speech– Feelings of guilt or unworthiness– Reduced self esteem or self confidence– Poor concentration or attention– Thoughts or acts of self-harm or suicide

• Symptoms are present for at least 2 weeks• Mild, moderate, and severe depression

Depression across the globe

• Depression is a universal phenomenon• Differences in presentation

– Psychological or somatic symptoms may dominate presentation

– Belief that depression results from an unknown medical illness, from possession by evil spirits or supernatural powers

– Related disease models (Patel et al 2001)• Thinking too much (kufungisisa) in Zimbabwe• Neurasthenia (shenjing shuairuo) in China• Anxiety (ghabrahat) in India• ‘Heart too much’ (pelo y tata) in Botswana

Prevalence of DepressionAuthor Year Location Sample (N) Disorder Classification Instrument Current 6 month 12 month lifetime Age of Women /

prevalence prevalence prevalence prevalence onset men

Weissman 1978 USA 511 MDE RDC SADS 4.3 20 1.6*Uhlenhuth 1983 USA 3161 MDE DSM III Checklist 5.1 2.5***

Regier 1993 USA ECA 18571 MDE DSM III DIS 2.2 2.7 4.9 25.6 1.8*Bland 1988 Canada 3258 MDE DSM III DIS 3.2 5.2 8.6 24.8 1.6**Canino 1987 Puerto Rico 1513 MDE DSM III DIS 3 3 4.6 29.5 1.3**Lepine 1989 France 1746 MDE DSM III DIS 4.5 16.4 29.2 2.4***Wittchen 1992 Germany 481 MDE DSM III DIS 5 9 29.7 3.5****Faravelli 1990 Italy 1000 MDE DSM III Flowchart 2.8 6.3 12.4 38.4 3.2*Karam 1992 Lebanon 526 MDE DSM III DIS 19 25.2 1.6***Hwu 1989 Taiwan 11004 MDE DSM III DIS 0.8 1.5 29.3 1.6***Lee 1987 Korea 5100 MDE DSM III DIS 2.3 3.4 29.3 2***Oakley Brown 1989 New Zealand 1498 MDE DSM III DIS 5.3 5.8 12.6 27.3 2.1**

Hollifield 1990 Leshoto 356 MDE DSM III DIS 12.4 1.6*Chen 1993 Hongkong 7229 MDE DSM III DIS 2 1.9Levav 1993 Israel MDE RDC SADS 3 1.3**Blazer 1994 USA NCS 8098 MDE DSM III-R CIDI 4.9 17.1 1.6*Kessler 1994 USA NCS 8098 MDE DSM III-R CIDI 10.3 17.1 23.6 1.6****Stefansson 1994 Iceland 862 MDE DSM III DIS 1.9 2.3 2.9 5.3 3.2*Carta 1995 Italy MDE DSM-III -R CIDI-I 13.3Bijl 1997 Netherlands 7076 MDE DSM-III -R CIDI

Lepine 1997 DEPRES 78463 MDE CIDI 6.9Belgium 5Germany 3.8France 9.1

Netherlands 6.9Spain 6.2UK 9.9

Pakriev 1998 Estonia 855 Any dep DSM III-R CIDI 30Lindeman 2000 Finland 5993 MDE DSM III-R UM-CIDI SF 9.3

Kessler 2000 ICPE 29644 Any mood DSM III-R CIDI 26Brazil 4.9 7.1 15.5

Canada 2.6 4.9 10.2Germany 3.6 9.6 17.1Mexico 2.3 4.8 9.2

Netherlands 4 7.7 18.9Turkey 3.7 4.2 7.3USA 5.1 10.7 19.4

Henderson 2000 Australia 10600 MDE DSM III-R CIDI-ADowrick 2000 ODIN CIDIPatrick D 2000 LIDO CIDI

In China, Suicide is the leading cause of death in persons age 15-34.In Europe, suicide is the 2nd cause of death in persons 15-34 after traffic accidents.

% of Women who have contemplated suicide

Experienced physical violence by intimate partner

Never Ever

Brazil (N=940)1 21 % 48 %

Chile (N=422)2 11 % 36 %

Egypt (N=631)2 7 % 61 %

India (N=6,327)2 15 % 64 %

Indonesia (N=765)3 1% 11 %

Philippines (N=1,001)2 8 % 28 %

Peru (N=1,088)1 17 % 40 %

Thailand (N=2,073)1 18 % 41 %

1:WHO (2001), 2:INCLEN - WorldSAFE (2001), 3:Hakimi M et al (2001).

Depression can be reliably diagnosed in primary care. Antidepressant medications and brief, structured forms of psychotherapy are effective for 60-80 % of those affected and can be delivered in primary care.

However, fewer than 25 % of those affected (in some countries fewer than 10 %) receive such treatments. Barriers to effective care include the lack of resources and lack of trained providers.

Treatment of depression in primary care

Study site % Recognized as depressed Treatment of those recognizedAntidepressants Sedatives

Ankara 28.2% 19.4% 29.0%Athens 32.4% 9.1% 45.5%Bangalore 46.2% 21.7% 21.7%Berlin 56.5% 11.4% 5.7%Groningen 63.2% 15.2% 16.5%Ibadan 63.0% 0.0% 35.3%Mainz 59.4% 10.5% 23.7%Manchester 64.3% 38.6% 12.9%Nagasaki 19.2% 40.0% 20.0%Paris 65.9% 31.8% 49.4%Rio de Janeiro 48.4% 5.1% 33.9%Santiago 72.6% 18.8% 40.0%Seattle 66.1% 46.3% 7.3%Shanghai 24.6% 0.0% 14.3%Verona 73.7% 25.0% 64.3%

Total 39.1% 22.2% 27.6%

WHO: Sartorius et al, 1995.

http://www.who.int/mental_health/mhGAP/en/

“The WHO mhGAP InterventionGuide will openthe door to more opportunitiesfor the management ofdisorders that contribute tosuffering among individualsand their families worldwide”said Thomas Insel, Director, National Instituteof Mental Health, USA.

Questions

What can we learn from effective treatment programs in developed and developing countries?

What are the best opportunities and ‘platforms’ to provide treatment?

What can we do here at UW to help advance effective treatment for common mental disorders worldwide?