Mental Health
By looking beyond mortality figures to consider the burden of disability in developing countries, the first edition of Disease Control Priorities in Developing Countries (Jamison and others 1993) revealed that mental health accounts for a substantial amount of the disease burden in these countries.9 Depression, schizophrenia, bipolar disorder, anxiety disorders, dementias, and epilepsy are conditions that do not appear as significant causes of mortality, but they seriously reduce the quality of life for individuals and their families. Disease burden estimates in DCP2 confirm that mental health contributes significantly to the global burden of disease. DCP2 also presents what is known about cost-effective interventions while emphasizing the need for further research to develop better ways to address the mental health burden.
"About 13 percent of all DALYs are due to neurological and psychiatric disorders."
About 13 percent of all DALYs are due to neurological and psychiatric disorders. Alzheimer's disease and other dementias account for 17.1 million DALYs and are twice as common among women as men, while epilepsy accounts for another 6.2 million DALYs and Parkinson's disease for 2.3 million DALYs. Depression is the most common psychiatric disorder, accounting for 51.9 million DALYs or 3.4 percent of the global burden of disease. It is ranked fourth among all causes of DALYs and is the leading nonfatal condition globally. It is also more common among women than among men. Schizophrenia, bipolar disorder, and panic disorder account for another 11.6 million DALYs, 9.7 million DALYs, and 4.5 million DALYs, respectively. Mental health conditions are common in developing countries, but are less frequently recognized, diagnosed, and treated than in developed countries.
"Depression is the most common psychiatric disorder, . . . ranked fourth among all causes of DALYs and . . . the leading nonfatal condition globally."
The interventions available for preventing and treating mental health problems in developing countries are relatively limited. Many neurological conditions, such as Alzheimer's disease and Parkinson's disease, have no cure, and preventive measures are also lacking. The major exception is stroke, for which preventive measures were discussed earlier. For other mental health problems, large advances have been made in both pharmacological treatments and psychosocial therapies, but many interventions are still focused on mitigating symptoms or easing the burden on families caring for members with mental health problems.
"For schizophrenia, depression, bipolar disorder, and panic disorders, a variety of pharmacological treatments are available . . ."
Some pharmacological treatments are available for Alzheimer's disease and other dementias, but most interventions for this disease aim to reduce stress and depression among patients' caregivers. For example, training caregivers about proper diet or establishing bowel and bladder routines can make caring for someone with Alzheimer's less stressful. For Parkinson's disease, treatments aim at symptomatic relief by means of pharmaceuticals, physical therapy, and traditional medicines. For schizophrenia, depression, bipolar disorder, and panic disorders, a variety of pharmacological treatments are available, including older mood stabilizers, for instance, lithium; antipsychotics, for example, haloperidol; and antidepressants such as tricyclic medications, which are also used to treat anxiety disorders. Psychosocial treatments, which consist largely of cognitive-behavioral approaches, have also proven to be effective.
While it is necessary to generate a wider range of interventions to address mental health problems, the quality of life for a large number of people in low- and middle-income countries could be substantially enhanced by applying interventions already demonstrated to be cost-effective. For people suffering from epilepsy, administering phenobarbitol helps avert seizures at a cost of US$89 per DALY averted. For Parkinson's disease, two interventions are reasonably cost-effective: l-dopa and carbidopa at US$1,500 per DALY averted and ayurvedic treatments at US$750 per DALY averted. Treatment of acute stroke because of vascular occlusion using aspirin costs only US$150 per DALY averted. Interventions to prevent the recurrence of stroke are cost-effective in part because they are easily targeted to a population that is known to face higher risks, costing US$70 per DALY averted for aspirin treatment, US$932 per DALY averted for dipyridamole and aspirin, and US$1,458 per DALY averted for carotid endarterectomy.
"Treatment of acute stroke because of vascular occlusion using aspirin costs only US$150 per DALY averted."
The variations in labor, transportation, and service delivery costs across regions generate significant differences in the cost-effectiveness of these treatments. For example, aspirin is the most cost-effective intervention for acute stroke in South Asia and Sub-Saharan Africa, whereas aspirin plus dipyridamole treatment is more cost-effective in the other developing regions.
"For psychiatric disorders, combining drugs with psychosocial treatment is generally the most cost-effective intervention."
For psychiatric disorders, combining drugs with psychosocial treatment is generally the most cost-effective intervention (table 5.2). For example, treating schizophrenia with older antipsychotic medications such as haloperidol along with family psycho-education is the most cost-effective intervention available, ranging between US$5,000 and US$8,000 per DALY averted in the Middle East and North Africa, South Asia, and Sub-Saharan Africa and between US$10,000 and US$17,000 per DALY averted in the other regions. Treating depression with new antidepressants such as Fluoxetine and group psychotherapy costs between US$2,000 and US$3,000 per DALY averted in all the regions. Treating panic disorders with newer antidepressant drugs such as Fluoxetine costs between US$1,000 and US$1,500 per DALY averted.
[Table .]
Addressing the burden of mental health in developing countries requires closing a treatment gap between what can be done for people with neurological and psychiatric disorders compared with what is currently being done. DCP2 identifies the available cost-effective measures, but closing this gap also relies heavily on general improvements in health systems. Cost-effective treatment largely involves outpatient care, but depends significantly on the ability of health professionals at the primary level to recognize symptoms and refer patients to appropriate care. It also requires better management of drug supplies to assure the availability and potency of drugs, along with counseling for patients and their families to encourage adherence. Research is needed to widen the range of available interventions, reduce the cost of current interventions, discover more cost-effective treatments, and, if possible, find ways to prevent or cure these debilitating conditions.
"Addressing noncommunicable diseases and injuries is not something that low- and middle-income countries can leave to the future."
