My talk on mental health in low and middle income countries as introduction to global mental health at Edna school in Somaliland

1. Global burden of mental health,
neurological and substance misuse
disorders: What are the implications
of this on Somaliland health system
Djibril I.M Handuleh, MBBS, MPH
Amoud Medical School
Borama, Somaliland
Brain Awareness advocacy Conference, Hargeisa Somaliland,
February 13, 2017
Public mental health

2. Mental health in low and
middle income countries
• 80% of the world population and
6% of the mental health research
goes to the developing world.
• Global burden of disease study
identified the huge burden of the
mental health disorders in these
countries.
• World mental health report
broadened the scope of mental
health beyond its clinical
boundaries to public health and
social determinants of health

3. • World health report 2001 was
exclusively on global mental
health and it was the first time
attention have been given to the
burden of mental health
disorders.

4. Global burden of disease
study findings
• neuropsychiatric disorders (which include
unipolar depressive disorder,
bipolar disorder, schizophrenia, epilepsy,
alcohol and drug use disorders,
dementias, anxiety disorders, mental
retardation and selected neurological
disorders) account for 9.8% of the total
burden of disease in LAMIC;
addition of self-inflicted injuries increases
this proportion to 11.1%.
• Unipolar depressive disorder accounts for
3.1% of the total burden of
disease attributable to non-communicable
conditions in LAMIC; this disorder is the
leading neuropsychiatric cause of burden of
disease.

5. • Self-inflicted injuries account for 1.5% of all
deaths in LAMIC; there are
considerable regional variations in this
proportion. Thus, self-inflicted
injuries account for .2% of total deaths in
Europe and Central Asia,
making them the fifth leading cause of
mortality in these LAMIC.
• Unipolar depressive disorders is the single
leading cause of Years Lived
with Disability (a measure of disease
burden which estimates the years of
health life lost through time spent in states
of less than full health); two
other mental disorders appear in the
leading 10 causes—schizophrenia
and alcohol use disorders

6. Global Burden of disease
study
• Commissioned by WHO/World Bank
to quantifying the global
burden attributable to different
diseases, injuries, and risks.
DALY = YLD + YLL
• Mental health disorders contribute
to 13% of global burden of diseases
• By 2030, depression will be second
leading cause of DALYs
• Globally the majority of people who
need mental health care don’t
receive it.

7. GBD study
• The first GBD study, GBD 1990,
quantified burden for 107 causes across
8 world regions.
GBD 1990 included these disorders
which grouped under neuropsychiatric
disorders:
• Unipolar major depression
• Anxiety disorders (GAD, PTSD and
panic disorder separately)
• Bipolar disorder
• Schizophrenia
• Drug use
• Alcohol use
GBD 1990 found depression to be the
leading cause of disability (YLDs)

8. GBD 2010
•
GBD 2010 quantified burden for
291 diseases, injuries and risks
for 187
countries, 21 world regions, 6
super-regions and the world.
This included 13 mental
disorders categorized into 9
groups:
• Depressive disorders – MDD
and dysthymia
• Anxiety disorders
• Schizophrenia
• Bipolar disorder
• Eating disorders – anorexia
and bulimia
• Disruptive behavioral
disorders – conduct disorder
and ADHD
• Pervasive developmental
disorders – autism and
Asperger’s disorder
• Idiopathic intellectual
disability
• Other mental disorders
• Murray CJL, Ezzati M, Flaxman AD, Lim S, Lozano
R, Michaud C, et al. GBD 2010: design,
definitions, and metrics. The Lancet
2012;380:2063-2066

9. • GBD 2010 quantified burden for 291
diseases, injuries and risks for 187
countries, 21 world regions, 6
super-regions and the world.
This also included five drug
disorders along with alcohol use
disorders:
• Cannabis
• Cocaine
• Amphetamines
• Opioids
• Alcohol use disorders

10. Calculating YLL and YLD
• YLLs = Attributable Deaths x Life
Expectancy
YLDs = Prevalent Cases x Disability Weight
Prevalent cases:
• Systematic review and extraction of
epidemiological data.
• Modelling the epidemiological data in Dis
Mod-MR.
• Use of prevalence output and population
data to ascertain prevalent cases.
Disability weights:
• Disability was defined as ‘any short or
long term health loss due to a
particular cause’.
• Population and online surveys with lay
descriptions presented as pairwise
comparisons

11. Prevalence of mental
health disorders
• WHO estimates that there are
450 million cases of mental health
patients(WHO 2001).
• The largest treatment gap exists
in low and middle income
countries.
• Basic mental health treatment
would lead to up to 3000 DALYs
saved per million population.
• Basic training of mental health
among general medical
practitioners can address this gap.

12. Determinants of mental
health disorders
• Social and economic
determinants are related
to the global mental
health pandemic.
• Poverty, gender
discrimination/violence
and wars are among the
top ones.
• understanding the
above socioeconomic
determinants are
important for planning,
developing. The
promotion and advocacy
of mental health among
other stakeholders is
vital too.
• Mental health disorders
lead individuals and
families into poverty

15. The treatment gap
between different regions
• Between 76%and 85%of people
with severe mental disorders
receive no treatment for their
disorder in low-income and
middle-income countries
• The corresponding range for high
income countries is also high
between 35%and 50%

16. • People with mental disorders
experience disproportionately
higher rates of disability and
mortality
• Suicide is the second most
common cause of death among
young people worldwide

17. Vulnerable groups to
mental health disorders
• These vulnerable groups may [but do not
necessarily) include members of households
living
• Poverty
• People with chronic health conditions
• Infants and children exposed to maltreatment
and neglect
• Adolescents first
exposed to substance use
• Minority groups
• Indigenous populations
• Older people
• People experiencing discrimination and
human rights violations
• Lesbian, gay, bisexual, and transgender persons
• prisoners
• People exposed to conflict, natural
disasters or other humanitarian emergencies

18. Human resource for
mental health
• The number of specialized and
general health workers dealing with
mental health in low-income and
middle-income countries is grossly
insufficient.
• Almost half the world's population
lives in countries where, on average,
there is one psychiatrist to serve
200 000 or more people
• Other mental health care providers
who are trained in the use of
psychosocial interventions are even
scarcer.

19. • Similarly, a much higher proportion of high-
income countries than low-income countries
reports having a policy, plan and legislation
on mental health
• For instance, only 36%of people living in low
income countries are covered by mental
health legislation compared with 92% in high-
income countries.
• Civil society movements for mental health in
low-income and middle-income countries are
not well developed.
• Organizations of people with mental
disorders and psychosocial disabilities are
present in only 49% of low-income countries
compared with 83%of high-income countries;
for family associations the respective figures
are 39% and 80% respectively

20. Poverty and mental health
a vicious cycle

21. Medications
• The availability of basic medicines
for mental disorders in primary
health care is notably low in
comparison to medicines available
for infectious diseases and even
other non communicable diseases
• Lack of professionals trained in
appropriate treatment and
prescription of medications.
• Non pharmacological interventions
are also lacking in LMICS.

22. Guess!!
• WHO definition of health is “a
state of complete physical, mental
and social well being and not
merely the absence of disease
and disability” WHO 1946
Do you think mental in the
definition is neglected in the public
health arena?

23. Mental health disorders
have another lethal link
• Physical health and mental health
association is widely proven
• Examples include diabetes,
coronary heart diseases, stroke,
infectious diseases etc.

24. Mental health
intervention
• Proven to be easy, avoidable and
cost effective.
• For instance, EU countries found
they needed to spend 3-4% of
their GDP on mental health.
• Cost related to untreated mental
health disorder include early
retirement, lost employment and
poor performance.

25. Reasons for poor mental
health among populations
• Services are not available when
needed.
• When it is available, it is not given
effectively and efficiently.

26. HOW TO ADDRESS THIS
GLOBAL ISSUE
• GLOBAL MENTAL HEALTH ACTION PLAN
2013-2020
• The vision of the action plan is a world
in which mental health is
• valued, promoted and protected,
mental disorders are prevented
• persons affected by these disorders are
able to exercise the full range of human
rights and to access high quality,
culturally-appropriate health and social
care in a timely way to promote
recovery, in order to attain the highest
possible level of health and participate
fully in society and at work, free from
stigmatization and discrimination.

27. GLOBAL MENTAL HEALTH
ACTION PLAN
• Its overall goal is to promote
mental well-being, prevent mental
disorders, provide care, enhance
recovery, promote human rights and
reduce the mortality, morbidity and
disability for persons with mental
disorders
• The framework provided in this
action plan needs to be adapted at
regional level in order to take into
account region-specific
situations

28. Mental health strategic
plan 2013-2020
• strengthen effective leadership and
governance for mental health.
• provide comprehensive, integrated
and responsive mental health and
social care services in community-
based settings.
• implement strategies for promotion
and prevention in mental health.
• strengthen information systems,
evidence and research for mental
health.

29. Six cross cutting issues
1. Universal health coverage:
2. Human rights
3. Evidence-based practice
4. Life course approach:
5. Multi sectoral approach
6. Empowerment of persons with
mental disorders and psychosocial
disabilities.

30. Top 10 leading causes of
DALYs

31. Important note
• Global disease burden has shifted:
• From communicable to non-
communicable diseases
• From YLLs to YLDs
• Mental and substance use
disorders make up a significant
component of
the changing global picture.
• While comprehensive, the mental
and substance use disorders
presented
here do not represent the full
picture of mental and substance use
burden

32. Mental health ward
vs
prison center

36. ANY QUESTIONS
Thanks for listening