Session 2: Carol Brayne


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Carol Brayne: Global Mental Health & Public Health

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  • Current aims to foster and support public health research training and service
  • 1 DALY = the loss of the equivalent of one year of full health Enables comparison of impact of disorders that cause early death but little disability (eg. drowning or measles) with those that do not cause death but do cause disability (e.g. cataract causing blindness) It combines YLL (years of life lost) due to deaths and YLD (years lived with disability) for equivalent healthy years of life lost through living in states of less than full health for cases of disease and injury incident
  • The prevalence of 10/66 dementia varied between 5·6% and 11·7% by site, whereas that of DSM-IV dementia was much lower ( 0.4% - 6.4 ). However, the false positive rate, which varied between 1% and 10% across regions and levels of education, might be one factor accounting for the higher prevalence of 10/66 dementia.
  • A high proportion of people needed care in particular in the Latin American sites.
  • population attributable fractions = represent the proportion of needing much care which could be avoided if depression, physical illnesses or dementia could be removed as a problem from these populations. And it is two thirds in the case of dementia.
  • What was found was that on the basis of empirical research, dementia was overwhelmingly the most important independent contributor to disability for elderly people in countries with low and middle incomes. And given the societal costs associated with disability, which are enormous, chronic diseases of the brain and mind deserve increased prioritisation.
  • Session 2: Carol Brayne

    1. 1. Global mental health & public health Carol Brayne Matthew Prina Cambridge Institute of Public Health
    2. 2. The Cambridge Institute of Public Health (CIPH) A federation and platform to foster and support public health research, training & service
    3. 3. Content <ul><li>Global burden and definitions </li></ul><ul><li>International studies focusing on older population </li></ul><ul><li>What disorders, how common and how important </li></ul><ul><li>Summary </li></ul>
    4. 4. <ul><li>Health “ a state of complete physical, mental , and social well-being, and not merely the absence of disease or infirmity ” </li></ul>WHO 1946
    5. 5. Prevalence of Mental Disorders <ul><li>450 million people worldwide suffer from neuropsychiatric conditions (WHO 2001) </li></ul><ul><li>10 % point prevalence of neuropsychiatric conditions in adults (WHO 2001) </li></ul><ul><li>25 % of individuals will develop one or more mental or behavioural disorder in their lifetime. </li></ul>
    6. 6. Mental Health & Mortality WHO 2010
    7. 7. Depression leading cause of burden of disease by 2030? WHO 2004
    8. 8. Barriers to mental health in health care <ul><li>Critical contributory factors include: </li></ul><ul><li>Deficiencies in information about prevalence, impact, and effective interventions. </li></ul><ul><li>Stigma and discrimination associated with ‘ abnormalities of the mind ’ </li></ul><ul><li>Low numbers and limited types of health workers trained and supervised in mental health care </li></ul><ul><li>Insufficient funding for mental health services </li></ul><ul><li>Mental health resources centralised in and near big cities and in large institutions </li></ul>Saraceno et al. Lancet 2007; 370:1164-74
    9. 9. Public Mental Health <ul><li>Main aim: ‘ to reduce the incidence, prevalence and impacts of mental disorders and improving the mental health status of population ’ ( Oxford Textbook of Public Health, 5 th edition ) </li></ul><ul><li>Secondary aim: ‘ to optimise physical health through mental and behavioural interventions ’ </li></ul><ul><li>Tools used are similar to other areas of PH: epidemiology, health promotion and prevention, health systems and services development, health economics, and monitoring and evaluation. </li></ul>
    10. 10. Measuring the prevalence of mental disorders example – later life
    11. 11. Ageing population across the world
    12. 12. Challenges of measurement <ul><li>Measurements: </li></ul><ul><ul><li>D isagreements about fundamental aspects of diagnoses in psychiatry </li></ul></ul><ul><ul><li>N o gold standards </li></ul></ul><ul><ul><li>V ariety of scales </li></ul></ul><ul><ul><li>Measurements applicable in later life </li></ul></ul><ul><ul><li>Measurements applicable to different cultures </li></ul></ul><ul><li>Episodic nature of psychiatric conditions. </li></ul>
    13. 13. Comparing international data <ul><li>Plethora of scales/methods </li></ul><ul><li>Concerns about cultural ‘ fit ’ </li></ul><ul><li>Treatment may need to be culture specific  ‘ culture bound syndrome ’ = disturbed behaviour, highly specific to certain cultural systems, which does not conform to Western nosological entities </li></ul><ul><li>Need cross cultural validity of measurement tools </li></ul>
    14. 14. 10/66 (Prince, Ferri and many colleagues) <ul><li>11 catchment areas / 7 countries (rural + urban) with excellent response rates. </li></ul><ul><li>Large study = roughly 2000 participants per centre </li></ul><ul><li>Full interviews last around 2-3 hours: </li></ul><ul><li>Collected data on: </li></ul><ul><ul><li>Mental disorders (GMS/AGECAT) </li></ul></ul><ul><ul><li>Physical disorders </li></ul></ul><ul><ul><li>Socio-demographics </li></ul></ul><ul><ul><li>Health service usage </li></ul></ul><ul><ul><li>Disability </li></ul></ul><ul><ul><li>Blood sample </li></ul></ul><ul><ul><li>Physical examination </li></ul></ul>
    15. 15. 10/66 sites
    16. 16. Dementia *Standardised for age, sex, and education. Prince et al. Lancet. 2008 August 9; 372(9637): 464–474.
    17. 17. Prevalence of depression Guerra et al. (submitted)
    18. 18. Needs for care
    19. 19. Need for care ‘much of the time’ independently attributable to different health conditions Condition Prevalence Adjusted Prevalence ratio PAF Major Depression 1.5% 2.0 2 % 3 or more physical illnesses 9.9% 1.9 23% Stroke 7.8% 2.5 10/66 Dementia 10.8% 17.8 65%
    20. 20. Disability <ul><li>“ The negative aspects of the interaction between an individual (with a health condition) and that individual's contextual factors (personal and environmental factors)” (WHO) </li></ul><ul><li>The WHO Disability Assessment Schedule (WHODAS) 2.0 was developed as a cross-cultural and culture-fair assessment tool to use in epidemiological studies. </li></ul><ul><li>It covers 6 domains: </li></ul><ul><ul><li>Understanding or communication </li></ul></ul><ul><ul><li>Getting around (mobility) </li></ul></ul><ul><ul><li>Self care </li></ul></ul><ul><ul><li>Getting along with people (interpersonal interaction) </li></ul></ul><ul><ul><li>Life activities </li></ul></ul><ul><ul><li>Participation in society (social aspects of disability). </li></ul></ul>
    21. 21. Dementia was found to be the largest contributor to disability <ul><li>Median Population-attributable prevalence fractions (IQR) for: </li></ul><ul><li>Dementia = 25.1 % (19.2 – 43.6) </li></ul><ul><li>Stroke = 11.4 % (1.8 – 21.4) </li></ul><ul><li>Limb Impairment = 10.5 % (5.7 – 33.8) </li></ul><ul><li>Arthritis = 9.9 % (3.2 – 34.8) </li></ul><ul><li>Depression = 8.3 % (0.5 – 23.0) </li></ul><ul><li>Eyesight problems = 6.8 % (1.7 – 17.6) </li></ul><ul><li>Gastrointestinal impairments = 6.5 % (0.3 – 23.1) </li></ul>
    22. 22. Overcoming Barriers to Mental Health in Health
    23. 23. Insufficient funding (% health expenditure) Prina et al. (In preparation)
    24. 24. Treatment gaps for mental disorders - world Kohn et al. WHO Bulletin 2004
    25. 25. Advocacy <ul><li>WHO advocacy objectives: </li></ul><ul><li>Promotion of human rights of the persons with mental disorders and their families </li></ul><ul><li>Monitoring the life conditions of people with mental illness and their families </li></ul><ul><li>Parity of care needs to be assured in all health schemes </li></ul><ul><li>10/66 has worked on basic research through to evidence for impact and advocacy </li></ul>
    26. 26. ‘ The Movement for Global Mental Health aims to improve services for people with mental disorders worldwide. In so doing, two principles are fundamental: first, the action should be informed by the best available scientific evidence; and, second, it should be in accordance with principles of human rights ’
    27. 27. Summary <ul><li>Defining, measuring and measuring impact key to addressing gaps </li></ul><ul><li>However, from public health angle the drivers of mental health in a population are related to wider factors </li></ul><ul><li>Advocacy needs to involve not only the existing mental health needs of populations but also those being generated by the circumstances in which people grow up and live </li></ul>
    28. 28. Thanks <ul><li>Matthew Prina </li></ul><ul><li>10/66 colleagues who generously share their studies </li></ul>