More developed countries
Less developed countries
Age
Population
% Total
Population
% Total
Total
1,246,044,208
5,849,173,772
60+
286,299,646
23
559,743,766
9.6
65+
209,944,236
16.8
368,844,926
6.3
70+
149,798,520
12
232,244,928
4
75+
98,386,763
7.9
131,452,967
2.2
80+
57,537,741
4.6
61,306,114
1
85+
27,695,698
2.2
21,681,356
0.4
90+
9,709,455
0.8
5,231,354
0.1
95+
2,245,103
0.2
823,236
<0.1
100+
378,087
<0.1
84,420
<0.1
The high prevalence of chronic noncommunicable diseases and poor mental health at later ages is a central challenge for all countries, whatever their income status. In fact, it is a greater challenge for LMICs. World Bank data show that health expenditures per capita vary considerably across country income categories, with annual per capita expenditures under $100 in some low-income countries but over $8,000 in the United States (in 2001 dollars), for example. Low-income countries have less than 20 physicians per 100,000 residents, while high-income countries may have as many as 500 or more (as in some countries of the European Union). The World Development Indicators of the World Bank provides detail on a variety of health access indices by country useful for tracking global disparities (http://databank.worldbank.org/data/views/variableselection/selectvariables.aspx?source=world-development-indicators) [3].
Disparities in access to mental health clinical specialists are even greater. Polling of neurologists by the World Federation of Neurology suggests differences in access between countries ranging from 6,240 people per neurologist in Europe to over 4 million per neurologist in Africa [4]. A survey of 192 countries, reported in the World Health Organization Mental Health Atlas [5], shows that the number of psychiatrists per 100,000 people ranges from 9.8 in Europe to <0.04 in Africa. Disparities in resources, personnel, and access to psychiatric services continue and show little signs of change, as shown in the most recent edition of the WHO Mental Health Atlas [6], which provides country-level descriptions of mental health policy governance, financing, and information systems, as well as estimates of mental health-care services delivery, access to clinicians and medications, and workforce training. Figure 11.1 shows the extreme differences in availability of mental health resources globally.
Fig. 11.1
Rate of mental health professionals per 100,000 population by WHO Member State, WHO Mental Health Atlas 2011. Reprinted with permission, WHO
LMICs thus face a perfect storm of challenges for addressing the mental health needs of older populations. Elements of this storm include rapid population aging (carrying with it greater prevalence of chronic conditions recognized as risk factors for depression), concentration of populations in urban centers (weakening traditional social supports), absent or still emerging social insurance systems (making it difficult to fund mental health services), and underdeveloped mental health services infrastructure (limiting access to effective treatments).
Recognizing these challenges, world bodies along with nongovernmental organizations have increased efforts to address global mental health. Some of the more prominent efforts include the WHO Mental Health Gap Action Programme (mhGAP) [7]. The program seeks to scale up services for mental, neurological, and substance use disorders in low- and middle-income countries (http://www.who.int/mental_health/mhgap/en/).
At its fourth global forum, mhGAP Forum vetted its 2012 Action Plan (http://www.who.int/mental_health/mhgap/forum_2012/en/index.html). The plan addresses mental health over the life span but includes many features relevant to the second 50 years of life: comorbidity of physical and mental disorders, discrimination, social determinants of health, spirituality, recovery, quality of health and social services, culture, suicide, vulnerable populations, scaling up and integrating mental health care into primary health care, caregiver and family support, role of NGOs, gender differences in mental health, and the role of e-mental health tools in implementation. In May 2013, the WHO World Health Assembly presented its draft comprehensive mental health action plan for 2013–2020. An allied effort is the WHO/World Federation for Mental Health “World Mental Health Day” (celebrated on October 10 each year). The 2013 theme was “Mental health and older adults” (http://www.who.int/mental_health/en/).
Another initiative is the National Institute of Mental Health (NIMH)-sponsored Collaborative Hubs for International Research on Mental Health (CHIRMH). This program established regional hubs in different parts of the world to increase research in mental health interventions in LMICs. CHIRMH explicitly seeks to reduce the mental health treatment gap, defined as the proportion of persons who need but do not receive care. As NIMH notes, “the treatment gap for mental disorders across the world is large and leads to chronic disability and increased mortality for those affected.” The program requires that “each regional hub must have an existing on-site administrative structure in its respective region along with scientific and mentoring capacity.” To date, NIMH has funded five such hubs: AFFIRM (AFrica Focus on Intervention Research for Mental health) in sub-Saharan Africa, RedeAmericas in South America, SHARE (South Asian Hub for Advocacy, Research and Education on mental health) in South Asia, LATIN-MH (Latin America Treatment and Innovation Network in Mental Health), and PaM-D (Partnership for Mental Health Development in Sub-Saharan Africa).
A related effort is the Global Alliance for Chronic Diseases (GACD) (http://www.gacd.org/), launched in 2009 [8]. The Alliance consists of national health research institutions (in the United States, the National Heart, Lung, and Blood Institute of NIH) and seeks to address prevention and treatment of chronic noncommunicable diseases, including mental illness. GACD focuses on LMICs and the low-income populations of more developed countries. The Alliance is broad and represents about 80 % of public health research funding worldwide. Member organizations include National Health and Medical Research Council (Australia), Institutes of Health Research (Canada), Ministry of Health and Academy of Medical Sciences (China), Medical Research Council (UK), NIH (US), Medical Research Council (India), Medical Research Council (South Africa), and the European Commission. Partners include the Pan American Health Organization, World Heart Federation, and National Institute for Medical Research (Tanzania).
GACD was part of the initial Grand Challenges Global Partnership (announced in 2007), which established priorities for reducing the burden of cardiovascular diseases, type 2 diabetes, chronic respiratory diseases, and certain cancers, which together account for about 60 % of all deaths worldwide. Mental health is part of the GACD agenda and will undoubtedly become more prominent.
Consistent with this growing effort in concern for global mental health is a series of new journals and opportunities for dissemination of research. For example, Lancet Global Health, launched in 2013, will focus exclusively on health in low- and middle-income countries and includes mental health as a key topical domain. PLoS Medicine has also established a series on Global Mental Health Practice.
Public education efforts for global mental health have also taken hold. An important effort is the Global Mental Health-Map (GMH-Map) [9], https://sites.google.com/site/gmhmap. GMH-Map is an effort of the Office of International Affairs, American Psychological Association. The website includes an extensive compilation of resources “to help people get a clearer sense of the GMH domain and to meaningfully connect and contribute to it.”
11.3 Global Prevalence of Mental, Neurological, and Substance Abuse and Related Disorders (MNS)
The prevalence and distribution of mental health disorders worldwide have become clearer through a series of cross-national population surveys that rely on screening and standardized clinical interviews, including the WHO Mental Health Surveys [10]. Using major depressive episodes (MDE) as an example, early results suggested substantial variability in 12-month age-adjusted prevalence, ranging from <1 % in Taiwan to 6 % in New Zealand [11]. Using the World Mental Health Composite International Diagnostic Interview (CIDI)-DSM-IV, age-adjusted 12-month MDE prevalence was higher in the United States and Europe (3.6–9.6 %) than in Asia and Africa (0.8–3.1 %) [12].
More recently, a 60-country study showed consistent cross-national associations between the presence of comorbid medical conditions and 12-month MDE prevalence, with a mean of 3.2 % in people without comorbidity and 9.3–23 % in people with comorbid conditions [13]. Recent results from WHO World Mental Health Surveys allow comparisons between 12-month prevalence of MDE in high-income countries and LMICs. Differences were not pronounced. The 12-month age-adjusted prevalence was 5.5 % in high-income countries and 5.9 % in LMICs. Screening prevalence in the surveys was also similar: 10.6 % in high-income countries and 10.5 % in LMICs [16], suggesting that the diagnostic approach was not biased. However, the association between mental health disorders and “days out of role,” a measure of disability, was quite variable, suggesting differences in the impact of symptoms and availability of treatment. Indeed, the surveys suggest most mental health disorders go untreated. Even in high-income countries, serious mental health disorders went untreated in about half the cases [14].
In the mental health surveys, anxiety and depressive disorders were more prevalent than impulse-control and substance abuse disorders. This association was also consistent across countries grouped by income. Country-level surveys in a variety of settings, from primary care to door-to-door targeted populations, confirm the WHO estimates of 12-month prevalence and show robust associations between risk of major depressive episodes and social disadvantage, stressful life events, and comorbid disease. Some recent examples include a 10/66 Dementia Research Group survey of Peru, Mexico, and Venezuela [15], the Sao Paulo Ageing and Health Survey [16], and an urban primary care study from China [17]. Increasing information about risk factors and correlates of poor mental health in LMICs is also becoming available for the first time, such as a population-based survey of suicide mortality in India [18].
Assessing the burden of mental ill health is a challenge, but a consistent body of research suggests it is substantial by every benchmark. The Global Burden of Disease Study examined incidence, prevalence, duration, and case fatality for 107 conditions and 483 disabling consequences of disease [19]. These estimates were used to develop the disability-adjusted life year (DALY), a summary measure of population health. DALYs are lost years of healthy life due to disease and combined loss of life and life lived with disability. By this metric, mental health disorders carry a disease burden as high as cardiovascular and respiratory diseases. Mental disorders were associated with a greater burden than the cancers or HIV because of their prevalence, early age of onset, lifelong duration, lack of effective therapy, and severe disability.
In 2005, mental, neurological, and substance abuse (MNS) disorders were responsible for about 13.5 % of global disease burden. Among the noncommunicable diseases (the source of half of global disease burden), MNS were responsible for 28 % of global burden [20]. By 2030, global disability due to MNS will increase to 14.4 %. Importantly, between 2005 and 2030, LMICs will see an increase in disease burden due to MNS. In low-income counties, the proportion of disease burden associated with MNS will increase from 9.1 to 11 % [20].
Unipolar depression is the third most prominent cause of global disease burden [21]. Among the MNS, unipolar depression is currently responsible for about 65.5 million DALYs worldwide. It is followed by alcohol-use disorders (23.7 million), schizophrenia (16.8 million), bipolar disorder (14.4 million), Alzheimer’s disease and the dementias (11.2 million), drug-use disorders (8.4 million), epilepsy (7.8 million), migraine (7.8 million), and panic disorder (7.0 million). In both high-income countries and LMICs, unipolar depression is first among the MNS in disease burden.
Given the high prevalence of MNS and their substantial disease burden, it is surprising that about a fifth of countries allocate less than 1 % of their health budgets to mental health care [22]. In fact, the mismatch may be even greater as we recognize the effect of MNS on risk of disability in other family members. For example, an increasing body of research has shown that maternal depression increases risk of underweight and stunted growth in children [20]. Spillover morbidity and disability among family members is likely to be important in late-life depression as well. Lay populations appear to recognize the disabling quality of mental health disorders. In the WHO World Mental Health Surveys, participants from high-income countries and LMICs both reported greater disability from mental health conditions than physical conditions [23].
11.4 Global Perspectives: Recognition of Depressive Disorders
11.4.1 Somatization
Somatic presentation of depressive symptoms is common. In a German study, patients with coexisting depressed mood and physical disease visited the doctor’s practice significantly more often than other individuals [24]. An Austrian study among Turkish immigrants showed that they scored significantly higher in somatic symptoms (headache, backache, and dry mouth) than Turkish patients seeing physicians in Turkey [25]. In the same manner, studies among Chinese, Indian, and Malay patients found that depression is more likely in elderly patients with multiple medically unexplained somatic symptoms [26, 27]. These findings suggest that somatic symptoms in the presentation of depressive disorders may be more important in LMIC populations. Mental health training in LMICs could profitably stress recognition of somatization in depression. Research involving older populations in LMIC is needed to determine if somatic presentation is typical in older populations as well.
11.4.2 Stigma
Stigma regarding mental illness is associated with greater psychiatric symptom severity and reduced treatment adherence [28]. Higher levels of internalized stigma are associated with lower levels of hope, empowerment, self-esteem, self-efficacy, quality of life, and social support. In the United States, depressed older adults endorsed a high level of public stigma, which lowered the likelihood of seeking mental health treatment [29]. African-American older adults in the United States were more likely to internalize stigma and endorsed less positive attitudes toward seeking mental health treatment than White elders. In the same manner, Asian-Americans and Latinos expressed greater shame and embarrassment about having a mental illness than Whites. Asian-Americans also expressed greater difficulty in seeking or engaging in mental health treatment [30].
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