Disease Control Priorities Related to Mental, Neurological, Developmental and Substance Abuse Disorders

111 Pages·2006·1.15 MB·English

by  World Health Organization

D C P
ISEASE ONTROL RIORITIES
M ,
RELATED TO ENTAL
N , D
EUROLOGICAL EVELOPMENTAL
S A D
AND UBSTANCE BUSE ISORDERS
Mental Health: Evidence and Research
Department of Mental Health and Substance Abuse
World Health Organization
Geneva
WHO Library Cataloguing-in-Publication Data
Disease control priorities related to mental, neurological, developmental and substance abuse disorders.
“This publication reproduced five chapters from the Disease control priorities in developing countries, second edition, a
copublication of Oxford University Press and The World Bank”—Acknowledgements.
Co-produced by the Disease Control Priorities Project.
1.Health priorities. 2.Health policy. 3.Mental health services. 4.Learning disorders. 5.Developmental disabilities.
6.Nervous system diseases. 7.Substance-related disorders. 8.Developing countries. I.World Health Organization.
II.Disease Control Priorities Project. III.Title: Disease control priorities in developing countries. 2nd ed.
ISBN 92 4 156332 X (NLM classification: WM 30)
ISBN 978 92 4 156332 1
© World Health Organization 2006
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Printed in Switzerland
Contents
Contributors v
Acknowledgements vii
Introduction Benedetto Saraceno ix
Chapter 1 Mental Disorders 1
Steven Hyman, Dan Chisholm, Ronald Kessler, Vikram Patel,
Harvey Whiteford
Chapter 2 Neurological Disorders 21
Vijay Chandra, Rajesh Pandav, Ramanan Laxminarayan,
Caroline Tanner, Bala Manyam, Sadanand Rajkumar,
Donald Silberberg, Carol Brayne, Jeffrey Chow,
Susan Herman, Fleur Hourihan, Scott Kasner, Luis Morillo,
Adesola Ogunniyi, William Theodore, and Zhen Xin Zhang
Chapter 3 Learning and Developmental Disabilities 39
Maureen S. Durkin, Helen Schneider, Vikram S. Pathania,
Karin B. Nelson, Geoffrey C. Solarsh, Nicole Bellows,
Richard M. Scheffler, and Karen J. Hofman
Chapter 4 Alcohol 57
Jürgen Rehm, Dan Chisholm, Robin Room, and Alan Lopez
Chapter 5 Illicit Opiate Abuse 77
Wayne Hall, Chris Doran, Louisa Degenhardt, and
Donald Shepard
Conclusion Shekhar Saxena 101
iii
Contributors
Nicole Bellows Ramanan Laxminarayan
University of California, Berkeley Resources for the Future
Carol Brayne Alan Lopez
University of Cambridge University of Queensland
Harvard School of Public Health
Vijay Chandra
World Health Organization, Bala Manyam
Regional Office for South-East Asia Texas A&M University HSC School of Medicine
Dan Chisholm Luis Morillo
World Health Organization Javeriana University
Jeffrey Chow Karin B. Nelson
Resources for the Future National Institute for Neurological Disorders and Stroke,
National Institutes of Health
Louisa Degenhardt
University of New South Wales Adesola Ogunniyi
University of Ibadan
Chris Doran University College Hospital, Nigeria
University of Queensland
Rajesh Pandav
Maureen S. Durkin World Health Organization,
University of Wisconsin Medical School Regional Office for South-East Asia
University of Wisconsin-Madison
Vikram Patel
Wayne Hall London School of Hygiene and Tropical Medicine
University of Queensland
Vikram Pathania
Susan Herman University of California, Berkeley
University of Pennsylvania
Sadanand Rajkumar
Karen J. Hofman University of Newcastle
Fogarty International Center, National Institutes of Health Bloomfield Hospital
Fleur Hourihan Jürgen Rehm
University of Newcastle, Australia Centre for Addiction and Mental Health, Canada
ISGF/ARI, Switzerland
Steven Hyman
Harvard University Robin Room
Harvard Medical School Stockholm University
Scott Kasner Benedetto Saraceno
University of Pennsylvania Department of Mental Health and Substance Abuse,
World Health Organization
Ronald Kessler
Harvard Medical School
v
Shekhar Saxena Geoffrey C. Solarsh
Department of Mental Health and Substance Abuse, Monash University, Australia
World Health Organization
Caroline Tanner
Richard M. Scheffler Parkinson’s Institute
University of California, Berkeley
William Theodore
Helen Schneider National Institute for Neurological Disorders and Stroke,
University of the Witwatersrand, South Africa National Institutes of Health
Donald Shepard Harvey Whiteford
Schneider Institute for Health Policy, University of Queensland
Heller School, Brandeis University
Zhen-Xin Zhang
Donald Silberberg Peking Union Medical College Hospital
University of Pennsylvania Chinese Academy of Medical Science
vi | Disease Control Priorities Related to Mental, Neurological, Developmental and Substance Abuse Disorders
Acknowledgements
This publication reproduces five chapters from the Disease Control Priorities in Developing Countries, Second Edition
(DCP2), a copublication of Oxford University Press and The World Bank, Editors: Dean T. Jamison, Joel G. Breman, Anthony
R. Measham, George Alleyne, Mariam Claeson, David B. Evans, Prabhat Jha, Anne Mills, Philip Musgrove.
DCP2 was funded in part by a grant from the Bill & Melinda Gates Foundation and is a product of the staff of the
International Bank for Reconstruction and Development/the World Bank, the World Health Organization, and the Fogarty
International Center of the National Institutes of Health. The findings, interpretations, and conclusions expressed in this vol-
ume do not necessarily reflect the views of the executive directors of the World Bank or the governments they represent, the
World Health Organization, or the Fogarty International Center of the National Institutes of Health.
For a full acknowledgement of all contributors to DCP2, please see pages xxv to xxxiv of DCP2.
The introduction and conclusion of the present volume have been developed by the Department of Mental Health and
Substance Abuse, World Health Organization, Geneva. The drafts of these sections were reviewed by the DCPP editors and
authors of the five chapters; their inputs are gratefully acknowledged. Additional comments were received from Mark van
Ommeren and Tarun Dua. Rosemary Westermeyer provided administrative support and assistance with production. The
graphic design of this book has been done by Dhiraj Aggarwal, e-BookServices.com, India.
WHO wishes to acknowledge inputs from the following individuals for their review of the draft chapters in a meeting
organized by WHO in 2004 - Karen Babich, Florence Baingana, Thomas Barrett, Sue Caleo, Dickson Chibanda, Christopher
Doran, Javier Escobar, Wayne Hall, Teh-wei Hu, Ramanan Laxminarayan, Yuan Liu, John Mahoney, David McDaid, Grayson
S. Norquist, Donald Shepard, Lakshmi Vijayakumar, Harvey Whiteford and Xin Yu. WHO staff members who assisted in this
review were: Anna Gatti, Colin Mathers, Vladimir Poznyak and Leonid Prilipko.
vii
Introduction
Benedetto Saraceno
Director
Department of Mental Health and Substance Abuse
World Health Organization
Geneva
This volume brings together five chapters from Disease together account for 10.96% of the global burden of disease
Control Priorities in Developing Countries, 2nd edition (DCP2 as measured by DALYs (Mathers, Lopez, and Murray 2006).
Jamison and others 2006). These chapters cover mental dis- Alcohol as a risk factor is responsible for 3.6% DALYs and
orders, neurological disorders, learning and developmental illicit drugs 0.6%. The burden associated with the full range
disabilities, and alcohol and illicit opiate abuse. The purpose of learning and developmental disabilities has not been esti-
of this special package is similar to the overall objective of the mated, but is likely to be substantial.
parent volume - to provide information on cost-effectiveness The proportion of the global burden of disease attribut-
of interventions for these specific groups of disorders. This able to mental, neurological and substance use disorders
information should contribute to reformulation of policies together is expected to rise in future. The rise will be particu-
and programmes and reallocation of resources, eventually larly sharp in developing countries, primarily because of the
leading to reduction of morbidity and mortality. projected increase in the number of individuals entering the
Why these five chapters together? The primary reasons age of risk for the onset of disorders. These problems pose
are both a conceptual basis and a practical consideration. a greater burden on vulnerable groups such as people living
Not only do these five chapters tend to cover brain and in absolute and relative poverty, those coping with chronic
behaviour, but also most departments and ministries of diseases and those exposed to emergencies.
health in developing countries deal with these areas together. While these figures are large and impressive, there are
Since the target readership of this volume includes policy many other varieties of burden that are not covered by the
makers and advisers in government departments in develop- DALY methodology but are extremely important for these
ing countries, it seemed sensible to publish these chapters disorders. These include burden to family members (time,
together. In addition, these areas have many other commo- effort and resources spent or not availed in the care of a sick
nalities - they are responsible for a large and increasing bur- family member) and lost productivity at the level of indi-
vidual, family or society in general. The DALY methodology
den, they are still low priorities in the public health agenda,
also does not take into account externalities including harm
the resource gap for their control is especially high and the
to others (quite substantial for alcohol and illicit drug use).
evidence for cost-effectiveness interventions against these
While the evidence for cost-effectiveness for interventions
disorders has become available only relatively recently. The
in this area using the DALY methodology is persuasive, it is
Department of Mental Health and Substance Abuse, World
likely that the case would be even stronger, if other kinds of
Health Organization (WHO), which is co-publishing this
burden are taken in account.
volume, is responsible for all these five areas.
WHO has recognized the need for enhancing the prior-
WHO also commissioned additional background reviews
ity given to mental and neurological disorders, learning and
to support the work of Disease Control Priority Project; these
developmental disabilities, and alcohol and illicit opiate abuse
are available on the DCPP website: (http://www.dcp2.org/
in several of its recent publications (WHO 2000; WHO 2001;
page/main/Research.html) and cover the following topics.
Room and others 2002; WHO 2004a; WHO 2004b). WHO
• Suicide and Suicide Prevention in Developing Countries has also recommended specific actions to be taken by coun-
(Vijayakumar) tries to strengthen the services available to individuals suffer-
• An International Review of the Economic Costs of Mental ing from these disorders (WHO 2001). However, the progress
Illness (Hu) in achieving these objectives has been slow and insufficient.
• An International Review of Cost-Effectiveness Studies for The data showing the magnitude and the burden of
Mental Disorders (Knapp and others) mental, neurological and substance use disorders are repeat-
• Mental Health and Labor Markets Productivity Loss and edly presented and discussed in international literature. Data
Restoration (Frank and Koss) showing the gap in resources and in treatment are also fre-
quently discussed. Finally, the evidence about the availability
The disorders and conditions covered in this volume of cost-effective interventions is becoming more available
are common and burdensome. Neuropsychiatry conditions than in the past.
ix
In spite of all these "arguments" (the burden, the gap and Centuries of neglect need to be compensated by positive
the availability of cost-effective interventions) still there is action. Economic arguments need to be buttressed by social
not enough clarity and understanding about the obstacles and humanistic arguments. Scientific evidence and econom-
that actually prevent low and middle income countries to ic costs and benefits need to be understood within the larger
improve mental health care and increase their investment in context of social responsibility.
mental health. The strong resistance to change and innova- What is needed is a radical change of paradigms for care
tion in mental health care in most countries of the world of individuals with mental and neurological disorders, learn-
have not been examined carefully. Some "reasons" to explain ing and developmental disabilities, and alcohol and illicit
the fact that too little is happening in mental health in spite opiate abuse:
of the evidence that something effective can be done, have
been provided: stigma about mental disorders prevent peo- • From Exclusion to Inclusion: The "exclusion approach" is
ple to be treated, primary health care doctors are not prop- not focused on the patient’s needs but rather on the envi-
erly equipped in recognizing and managing mild and mod- ronment's perception and needs. This approach results in
erate mental disorders, general practitioners and specialist an emphasis on security issues, including an over-estimate
do not recognize the important implications of comorbidity of dangerousness and a perception that mental disability
thus ignoring the mental health component of many physical makes people unable to take responsibility for themselves
diseases. These explanations are all true but probably many and others. Shifting the paradigm from exclusion to inclu-
others are not considered and they may prove to have an sion facilitates care in the community.
equal or even bigger influence in preventing more and better • From biomedical to biopsychosocial approach: In 1977,
investments in mental health. George Engel coined the expression "biopsychosocial"
However, better evidence on cost-effectiveness is likely to to describe the need in medicine for a new paradigm
make the case for prioritization of these disorders stronger that would go beyond the traditional biomedical and
but there are other kinds of arguments that can help build reductionist model. Today, the adjective 'biopsychoso-
the case (Patel, Saraceno, and Kleinman 2006). There is cial' is frequently used to define that which is supposed
abundant evidence that mental health is closely linked with to be an integral approach to medicine. However, it has
many global public health priorities. Mental health inter- become progressively more meaningless and ritualistic.
ventions or principles must be tied to many programmes This schism between the ritualistic use of holistic notions
dealing with physical health problems. The case is not that and the practice of medicine, which is still strongly orient-
we need to prioritize depression because it is co-morbid ed towards the biological paradigm, is particularly evident
with, for example, HIV/AIDS, but that planning a health in the field of mental health. Shifting from a biomedical
initiative for HIV/AIDS without a depression intervention approach to a biopsychosocial one would cause important
component would be denying individuals the best possible changes in the formulation of mental health policies, in
treatment for HIV/AIDS. It is unethical to deny effective, the creation and financing of mental health programmes,
feasible and affordable treatment to millions of persons in the daily practice of services and in the status of care
suffering from treatable disorders. Mental, neurological, providers. Such changes imply the recognition of the role
developmental and substance use disorders are just as severe of users and families, the recognition of the role of the
and disabling as various infectious diseases; those who suf- community, not just as an environment, but as a generator
fer from these disorders need treatment, as without it they of resources that must go hand in hand with the resources
may be disabled for long periods. We should also be aware provided by the health services and finally, the recognition
that those who suffer from these disorders are often unable of the role of sectors beyond health, such as social security,
to advocate for their rights of access to affordable, evidence- social assistance, welfare and the economy in general.
based treatments. • From Short Term Treatment to Long Term Care: A
Besides the right to treatment, there is also the larger radical shifting of the care paradigm is required. Health
question of citizenship rights. Individuals with mental, neu- systems are conceived and organized to respond to acute
rological, developmental and substance use disorders remain cases (hospital model). After the acute phase is resolved,
one of the few groups of persons whose citizenship rights the patient enters a limbo of infrastructures, human
are systematically denied or abused by society. Ignorance, resources, skills and responsibilities. The question is, how
prejudice and discrimination result in large numbers of can the entire health system serve the needs of the patient
individuals suffering from these disorders being excluded when he or she requires long term care? And this is not
from society- either by long-term incarceration in mental just for mental, neurological, learning and substance use
institutions or by denying them participation in work and disorders, but for many chronic conditions requiring
family life. To put a stop to this, we will need to increase rec- long-term care (HIV/AIDS or tuberculosis, for example).
ognition of those rights in the community and among health In other words, we need a radical shifting from a model
workers, ensure those rights are monitored and enforced and centred on the space location of the provider (hospitals,
provide technical and financial support for health care and outpatient clinics) to one centred on a time dimension of
legal systems to reform. the client.
x | Disease Control Priorities Related to Mental, Neurological, Developmental and Substance Abuse Disorders
• From Morbid to Co-Morbid: Real patients are more REFERENCES:
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Introduction | xi