Chapter 2 Literature Review Literature Review
2.3. Current Global State of Mental Illness
2.3.2. The burden of mental disorders
complementary-alternative medical sector while Whites were more likely to have seen a psychiatrist (Seedat et al., 2008).
A number of other important small scale studies of the prevalence of mental disorders have also been conducted locally. For example, an epidemiological study conducted by Havenaar, Geerlings, Vivian, Collinson and Robertson (2008) in historically disadvantaged urban and rural communities in South Africa revealed a high prevalence of mental health and substance abuse problems. More than one-third (34.9%) of their community sample reported high levels of anxiety or depression symptoms. Other local researchers estimated that about 17% of the total population experienced a psychological disorder in 2007 (Lund et al., 2008).
An important conclusion to note is that the high prevalence of psychiatric conditions in Africa is equivalent with that of international communities (Hugo et al., 2003; Kaliski, 2001; Williams et al., 2008).
High prevalence rates for mental illness reported in reviewed epidemiological studies should signify a need for the adequate distribution of knowledge and services pertaining to mental health. However, it is disconcerting that despite evidence of high prevalence of mental illness, the public still lacks mental health literacy and mental health services remain low on the priorities of most governments in low and middle income countries, South Africa included (Gureje & Alem, 2000; Mkhize & Kometsi, 2008). Moreover, while mental health literacy has been studied widely and comprehensively elsewhere (Bartlett, Travers, Cartwright & Smith, 2006; Jorm, 2000; Jorm, Barney, Christensen et al., 2006), it is a subject that has not received sufficient attention locally.
between the Harvard School of Public Health, the WHO, and the World Bank (Lopez & Murray, 1998; Mathers, Lopez, & Murray, 2006; Murray & Lopez, 1996).
According to Murray and Lopez (1998), the main aims of the GBD studies were:
1) To systematically incorporate information on non-fatal outcomes into assessment of health status;
2) To ensure that all estimates and projections were derived on the basis of objective epidemiological and demographic methods; and
3) To measure the burden of disease using a metric that could also be used to assess the cost-effectiveness of interventions.
Pruss-Ustun, Mathers, Corvalan and Woodward (2003) also add that the GBD studies aimed to quantify the burden of premature mortality and disability for major diseases or disease groups. According to Mathers et al (2006), the WHO undertook an assessment of the second GBD study for the years 2000 to 2002, with consecutive revisions and updates published annually in the WHO’s world health reports. These authors state that the second GBD study expanded the framework of the 1990 study to: 1) quantify the burden of premature mortality and disability by age, sex, and region for 136 causes; and 2) analyse the contribution of this burden of major physiological, behavioural and social risk factors by age, sex and region.
Through the GBD study, a new measure, the disability-adjusted life-year (DALY), was developed and applied to estimating the burden of disease for more than 100 causes (Murray, Lopez & Jamison, 1994). The DALY measures the future stream of healthy years of life lost due to each incident case of disease or injury by adding together years of life lost (YLLs) due to premature mortality, and years of life lived with disability (YLDs) weighted according to the severity of the disability (Bradshaw et al., 2003; Flisher, 2007; Pruss-Ustun et al., 2003). For example, disability caused by major depression is considered equivalent to that caused by blindness or paraplegia, and disability caused by active psychosis, as seen in schizophrenia, is estimated as somewhere between paraplegia and quadriplegia (Ustun, 1999).
Lopez, Mathers, Ezzati, Jamison and Murray (2006) state that the 1990 GBD study confirmed what many health workers had suspected for some time, namely, that non-communicable diseases and injuries were significant causes of the health burden in all regions. They add that neuropsychiatric disorders and injuries in particular were major causes of lost years of healthy life as measured by DALYs, and were vastly under-appreciated when measured by mortality alone. To
substantiate, Murray and Lopez (1996) report that of the ten leading causes of disability worldwide in the 1990 GBD study, measured in years lived with a disability, five were the following psychiatric conditions: unipolar depression, alcohol use, bipolar affective disorder, schizophrenia and obsessive-compulsive disorder.
Unipolar depression alone accounts for more than 10% of the years of life lived with a disability worldwide (Jenkins, 1997; Vos et al., 2012). Table 2.1 below presents a comprehensive list of the world leading causes of disability. The original GBD study also estimated that non-communicable diseases, including neuropsychiatric disorders, caused 41 percent of the GBD in 1990, only slightly less than communicable, maternal, perinatal and nutritional conditions combined at 44 percent (Lopez et al., 2006). According to Jenkins (1997), psychiatric and neurological conditions combined account for 28% of years of life lived with disability in all regions except Sub-Saharan Africa where they account for 16% of total disability. This author adds that when years of life lived are combined with years of life lost and actual mortality rates into disability life years, then psychiatric and neurological conditions account for 10.5% of the GBD.
Table 2.1: World leading causes of disability, 1990
Source: Murray & Lopez (1996, p.21)
A summary of the principal findings of the second GBD study is provided in Table 2.2 below. Regarding the leading causes of disability from the same study, Lopez et al. (2006) provide the following summary of key findings: 1) neuropsychiatric conditions, vision disorders, hearing loss and alcohol use disorders dominate the overall burden of non-fatal disabling conditions; 2) in all regions, neuropsychiatric conditions are the most important causes of disability, accounting for more than 37% of YLD among adults aged 15 years and older worldwide; 3) the disabling burden of neuropsychiatric conditions is almost the same for males and females, but major contributing causes are different; and 4) while depression is the leading cause of disability for both males and females, the burden of depression is 50% higher for females than males, and females also have higher burdens from anxiety disorders, migraine and senile dementia. Murray and Lopez (1996) add that alcohol use was found to be the leading cause of male disability, and the tenth largest in women, in the developed regions. Finally, more than 85% of disease burden from non-fatal health outcomes occurs in low- and middle-income countries, and South Asia and Sub-Saharan Africa account for 40%
of all YLD.
Table 2.2: The findings of the second GBD study
Source: Lopez et al. (2006, p.8)
Locally, although South Africa is one of the few countries in sub-Saharan Africa that produces national cause of death statistics, the country is considered deficient, with significant under-registration and misclassification (Bradshaw et al., 2003). With the lack of reliable data in South Africa, Bradshaw (1996) questions whether the DALY could be estimated for South Africa. Nevertheless, the first South African attempt to estimate DALYs was published by Bradshaw et al. (2003) in their study titled “Initial burden of disease estimates for South Africa, 2000”. This was
followed by Norman, Bradshaw, Schneider, Pieterse and Groenewald’s (2006) study titled “Revised burden of disease estimates for the comparative risk factor assessment, South Africa 2000”. Despite uncertainty in the estimates, these studies provide important information to guide public health responses to improve the health of the nation (Bradshaw, Norman & Schneider, 2007).
The WHO’s estimates place the burden from non-communicable diseases in South Africa as two to three times higher than that in developed countries (Mayosi et al., 2009). The key results of the initial South African DALY study provided by Bradshaw et al. (2003) are summarised as follows: 1) non-communicable diseases accounted for 37% of deaths, followed by HIV/AIDS, which accounted for 30%; 2) females have a higher proportion of HIV/AIDS and non-communicable diseases and a lower proportion of injury deaths than males; and 3) HIV/AIDS, homicide/violence, tuberculosis and road traffic accidents were leading the top 20 YLLs. Table 2.3 and Table 2.4 below show a clearer and more detailed presentation of these results.
Table 2.3: Results of the initial South African DALY study
Source: Bradshaw (2003, p.684)
Table 2.4: Causes of premature mortality in the South African DALY study
Source: Bradshaw (2003, p.685)
Following the initial national burden of disease study for South Africa, the second phase was revised to provide information for the Comparative Risk Factor Assessment which required DALY estimates for single causes (Norman et al., 2006).
While the broad profile remained unchanged, the main differences between the initial and revised estimates, as reported by Norman et al. (2006), included the following: 1) the revised number of deaths was 520 000 compared with 550 000; 2 the revised proportion of deaths due to HIV/AIDS was 25.5% compared with 30%;
and 3) the number of injury deaths was adjusted down by about 10 000 as a result of the decline observed in the more recent empirical data. The revised DALY estimates also highlighted the magnitude of neuropsychiatric problems, which ranked third as a category, following HIV/AIDS and other infectious disease categories (Bradshaw et al., 2007). Of significance was a warning by Abegunde, Mathers, Adam, Ortegon and Strong (2007) that the burden of disease related to non-communicable diseases was predicted to increase substantially in South Africa over the next decades if measures were not taken to combat the trend. In line with this prediction, diseases are on the increase in rural communities in South Africa, and they disproportionately affect poor people living in urban settings, and are driving a rise in the demand for chronic disease care (Mayosi et al., 2009).
When making projections into 2020 using data from the GBD studies, Murray and Lopez (1996) make the following two significant pronouncements relevant to mental health: 1) in the developing regions where four-fifths of the planet’s people live, non-communicable diseases such as depression and heart diseases are fast replacing traditional illnesses, such as infectious diseases and malnutrition, as the
leading causes of disability and premature death; and 2) by the year 2020, non- communicable diseases are expected to account for seven out of every ten deaths in the developing regions, compared with less than half today. Table 2.5 below provides a graphical presentation of the projected in the rank order of disease burden for 15 leading causes, worldwide, 1990 and 2020. Of significance to note in Table 2.5, unipolar major depression was the fourth leading cause of disease burden in 1990 and is projected to move up to the second leading position in 2020. Within this overall picture, the contribution of psychiatric disorders to the global disease burden in 2020 is expected to be immense. The projections show that psychiatric and neurological conditions could increase their share of the total GBD from 10.5% to 15% in 2020 (Jenkins, 1997).
Table 2.5: Projected rank order change of disease burden in 1990 and 2020
Source: Murray and Lopez (1996, p.4)
Given the high prevalence of mental illness across the globe, it is likely that the emotional and financial burdens on patients, their family and society as a whole are enormous. The WHO (2003) report asserts that the economic impacts of mental illness affect personal income, the ability of the ill persons, and often their care givers, to work, productivity in the work place and contributions to the national economy, as well as utilisation of treatment and support services. Mental disorders are the second most common reason for medical boarding in South Africa (Singh & Mkhize, 2006). Costello et al. (2005) also add that in a world of scarce healthcare resources, it is important to understand the size of the burden to the community caused by these disorders. They emphasise that burden, in terms of numbers affected, has an impact on the individual, and cost to the community is a crucial factor in the battle for resources for treatment and prevention.
Nevertheless, despite this evidence of the high burden of mental disorders, the overwhelming majority of people suffering from mental illness do not receive care, and many of those who do access care receive suboptimal care (Flisher, 2007).
Where there are effective treatments, they are frequently not available to those in greatest need. Furthermore, while advances have been made in general health promotion and prevention, the same cannot be said for mental disability. This is because ignorance, prejudice and stigma are still very widespread (Burns, 2011).
In summary, the GBD studies have been eye-opening for public health in terms of mainstreaming mental health. They have highlighted the public health significance of mental disorders (Ustun, 1999), and have attracted the attention of policy makers and public health experts alike, because they provide a common metric for evaluating and priority-setting across a wide range of health problems (Ustun, Ayuso-Mateos, Chatterji, Mathers & Murray, 2004). These studies have also demonstrated that mental disorders are strongly related both to non- communicable diseases and other health challenges such as HIV, tuberculosis and injuries, and can increase the risk of these diseases, which in turn increases the risk for mental health disorders (Mayosi et al., 2009).
Jenkins (1997) adds that the GBD studies have provided an essential bedrock of data to demonstrate the cost of not taking proper action with regard to mental health. Mounting evidence of the massive global health burden of mental illness has also resulted in the launch of a United Nations collaborative initiative, led by the WHO, to improve the mental health of the world’s underserved populations. This initiative seeks to raise the awareness of the world’s policy makers,
to support countries to prepare and implement mental health policies, and to promote international collaboration and technical support for mental health programmes and services (Jenkins, 1997b). Ustun et al. (2004) conclude that it is imperative to investigate how these findings and initiatives can be applied to policy-making, planning and programme implementation for the benefit of improved world mental health. This expectation has direct implications for researchers of mental health literacy as the public’s failure to recognise mental illness and professionals’ misunderstanding of the way the public conceptualise mental illness may hinder any efforts to promote mental health in general.