Comprehensive Psychiatry
(Official Journal of the American Psychopathological Association)
VOL. 38, NO. 2
MARCH/APRIL 1997
P s y c h i a t r y and Health in L o w - I n c o m e P o p u l a t i o n s
Leon Eisenberg
Although mental health problems constitute 8.1% of
the global burden of disease (GBD), mental health has
been largely missing from the international health
agenda. The discrepancy between needs and services
is likely to increase in the next millennium. Depression
alone is currently the fourth leading cause of disabilityadjusted life-years (DALYs) the world over and is
projected to become the second leading cause by the
year 2020. The nations of the world must make a
major commitment to upgrade the quality of mental
health services, including early detection and prevention of psychiatric problems in childhood and adolescence; to institute the collection of systematic data on
the global burden of alcohol and drug abuse and to
develop innovative treatment and preventive mea-
sures; and to provide substantial support for research
on treatment effectiveness. Because hunger, deprivation, and violence affect women disproportionately,
there is a pressing need for coordinated efforts to
improve state gender policies (including equal educational opportunity and improved health care for
women) and to interdict domestic violence. In the
words of Boutros Boutros Ghali, the Secretary General of the United Nations: "Medical and social issues
which are often viewed separately must be dealt with
as a w h o l e . . , the priority of mental health must be
h e i g h t e n e d . . , development policies m u s t . . , protect
and promote mental health."
N 1995, my colleagues and I completed a report
on world mental health.1 It outlines the extent
of the problems and the priorities for intervention
among low-income populations. Our most prominent finding was the interconnectedness of health
problems, such as depression, heart and lung diseases, sexually transmitted diseases, and other
behavior-related diseases, on the one hand, and of
psychosocial pathologies, such as violence, alcoholism, abuse of women and children, and underlying
social conditions such as war, poverty, and discrimination, on the other. They form self-perpetuating
spirals.
At a press conference to launch the book on May
15, 1995, at the United Nations, Secretary General
Boutros Boutros Ghali stated:
porate morbidity and mortality and be sufficiently
broad to include suffering and handicap. One
answer is the Disability-Adjusted Life-Year
(DALY). 2 The DALY is a statistic developed to
summarize in a single number the impact of
premature death, as well as the suffering and disability, resulting from specific disease conditions.
Age at death, as well as death itself, is taken into
account by subtracting the age at death from life
expectancy remaining at that age to compute "years
of life lost." In order not to undervalue years lost in
developing countries, the figure for life expectancy
is that of the developed world. To take suffering
and disability into account, each surviving year is
adjusted by the duration and severity of disablement (i.e., blindness or paralysis) resulting from
disease. The focus is on health status; life is valued
I
This R e p o r t . . . reminds us of the great human suffering
caused by mental illness . . . the international community
has risen to many challenges in the past. Now it must do the
same [for] mental health... The challenge is to combine
concern for mental health.., with humanitarian assistance
and protection efforts. Development policies mast . , .
protect and promote mental health.
DISEASE BURDEN
What metric is suitable for measuring the global
burden of disease (GBD)? The statistic must incor-
Copyright@ 1997by W.B. Saunders Company
From the Department of Social Medicine, Harvard Medical
School, Boston, MA.
Presented at the Seventh Congress of the International
Federation of Psychiatric Epidemiolog~; Santiago de Compostela, Spain, August 29 to September 1, 1996.
Address reprint requests to Leon Eisenberg, M.D., Department of Social Medicine, 641 Huntington Ave, Boston, MA
02115-6019.
Copyright © 1997 by W.B. Saunders Company
0010-440X/97/3802-0007503.00/0
ComprehensivePsychiatry,Vol. 38, No. 2 (March/April), 1997: pp 69-73
69
LEON EISENBERG
70
precisely the same whenever it is in jeopardy, and
no financial data are included.
The Burden of Mental Illness
Using the DALY as the basic statistic, the World
Development Report 2 concludes that mental health
problems make up 8.1% of the total GBD. Of that
8.1%, the largest contributors are depressive disorders, self-inflicted injuries, Alzheimer's disease
and other dementia, and alcohol dependence, followed by epilepsy, psychoses, drug dependence,
and posttraumatic stress disorder. Depressive and
anxiety disorders account for between one quarter
and one third of all primary health care visits
worldwide. 3,4 When appropriately diagnosed and
treated, suffering is alleviated, disability prevented,
and function restored; when ignored, major losses
persist. 5 By the year 2025, three quarters of all
elderly persons with dementia--about 80 million-will live in low-income societies. Mental retardation and epilepsy rates are three to five times higher
in low-income societies compared with industrialized countries. In some Asian and African countries, up to 90% of patients with epilepsy--a
treatable condition for which cost-effective drug
therapy is available--do not receive anticonvulsants. 6
In addition to that 8%, as much as an additional
34% of the GBD is due to disorders that are
behavior-related, such as violence, smoking and
drinking, AIDS and other sexually transmitted
diseases, motor vehicle and other unintentional
injuries, and gastrointestinal diseases that stem
from failure to follow sanitary practices. An estimated 5% to 10% of all persons on earth are
affected by alcohol-related diseases. Narcotics and
other illicit drugs constitute a large and rapidly
increasing source of morbidity in poor and rich
societies alike. Thus, more than one third of the
GBD is potentially preventable by changing behavior, a challenge that will require large-scale interventions to influence social messages, as well as
counseling for individuals.
The World Health Report 7 lists, in separate
tables, the 10 leading causes of mortality, the 10
leading causes of morbidity, and the 10 leading
causes of disability. No psychiatric disorder appears on the mortality list; neurotic, stress-related,
and somatoform disorders together make up the
third most important cause of morbidity. However,
in terms of chronically disabled persons, mood
Table 1. Top 10 Causes of DALYs Worldwide for Both
Sexes in 1990
Diseaseor Injury
DALYs(×103)
Cumulative%
All causes
1. LRI
2. Diarrheal diseases
3. Perinatal conditions
4. Depression
5. iHD
6. Stroke
7. Tuberculosis
8. Measles
9. Road traffic accidents
10. Congenital anomalies
1,379,238
112,898
99,633
92,313
50,810
46,699
38,523
38,426
36,520
34,317
32,921
8.2
15.4
22.1
25.8
29.2
32.0
34.8
37.4
39.9
42.3
Abbreviation: LRI, lower-respiratory infection.
disorders are the most important single cause;
mental retardation is fourth, epilepsy sixth, dementia seventh, and schizophrenia ninth.
Even more striking is a recent analysis undertaken by Murray and Lopez 8 of the Harvard Center
for Population and Development Studies. Depression was the fourth leading cause of DALYs in
1990, exceeded only by lower-respiratory infections, diarrheal diseases, and perinatal conditions
(Table 1).
Twenty-five years from now, depression will be
second only to ischemic heart disease (IHD) as a
cause of GBD (Table 2). Whereas IHD will account
for 5.9% of the total GBD, depression will account
for 5.7%. Despite the fact that neuropsychiatric
conditions make up five of the 10 most important
causes of long-term disability, despite the fact that
depression alone is currently the fourth most important cause of DALYs, and despite the fact that
depression will be the second leading cause 25
Table 2. Top 10 Causes of DALYs Worldwide for Both
Sexes in 2020
Diseaseor Injury
DALYs(× 103)
Cumulative%
All causes
1. IHD
2. Depression
3. Road traffic accidents
4. Stroke
5. COPD
6. LRI
7. Tuberculosis
8. War
9. Diarrheal diseases
10. HIV
1,388,836
82,325
78,662
71,240
61,392
57,587
42,692
42,515
41,316
37,097
36,317
5.9
11.6
16.7
21.1
25.3
28.4
31.4
34.4
37.1
39.7
Abbreviations: COPD, chronic obstructive pulmonary disease; LRI, lower-respiratory infection; HIV, human immunodeficiency virus.
MENTAL HEALTH IN LOW-INCOME POPULATIONS
years from now, mental health is largely missing
from the international health agenda.
Promising Solutions
Despite widespread pessimism about mental
disorders in public health circles, much can be
accomplished by applying present means. We have
unequivocal evidence for the effectiveness of pharmacologic, psychosocial, and combined treatments
in depression 9,1° and anxiety disorders] I,j2 as well
as for specific interventions to prevent certain
developmental disorders (iodinization of salt, environmental lead abatement, immunizations, perinatal care, and so on). ~3
The single most important issue is to give
priority to mental health around the world. In the
words of Secretary General Boutros Boutros Ghali:
,.. Medical and social issues which are often viewed
separately must be dealt with as a whole.., the priorityof
mental health must be heightened ... resources must
expand ... responsibilities must be recognized more
completely.
Key Clinical Initiatives
A major commitment to upgrade the quality of
mental health services. The care of the mentally
ill should be specified in national and regional
health plans and should receive adequate budgetary
allocations. Primary health care must be "reengineered" to improve the treatment of neuropsychiatric disorders. Improvements in mental health
systems require rational drug policies for psychotropic medications and reliable provision of adequate drug supplies. The human rights of patients
require protection in mental health legislation.
A small cadre of well-trained mental health
professionals (including, in particular, psychiatric
nurses) is essential to mental health programs in
order to design and implement training programs,
provide consultation to general health workers, and
supervise the care of the chronically mentally ill. At
the same time, major efforts are necessary to
educate generalist physicians about psychiatric
conditions, to improve behavioral science teaching
in medical education, and to provide in-service
training for practitioners.
Better mental health services for children and
adolescents, including early detection and prevention. Priority should be given to providing effective services integrated within all forms of health
care. Early detection of epilepsy and appropriate
71
medication to control seizures will enable children
with the disorder to participate fully in school, to
prepare for work, and to avoid the burns, injuries,
educational failure, and stigma associated with the
disorder. Prevention of mental retardation can be
achieved through birth planning, prenatal and perinatal care, hospital deliveries for difficult births,
immunization, optimal nutrition (calories, protein,
and micronutrients), home visits and day care, child
safety measures, and school-based programs on
family life and sexuality. ~3
Public schools are the principal social institution
for furthering the cognitive and emotional development of children. Teachers can learn to recognize
signs and symptoms of mental illness and child
abuse, to manage early problems in the classroom,
and to refer to those children requiring more
assistance to mental health facilities.
Systematic efforts to assess the global burden of
alcohol and drug abuse, to reduce demand, and to
develop treatment and prevention programs. In
no other area of mental health is there such a lack of
reliable, systematic data on the severity, magnitude,
and distribution of the problem needed to develop
effective policy strategies than in the area of illicit
drugs. International bodies must increase their
capacity for meaningful data gathering. Governments must develop stronger policies to reduce
demand. Public education is crucial to prevent the
onset of use among the young. Traditional and
nontraditional treatment approaches at the community and individual levels need implementation and
rigorous evaluation.~4
Support for research. Ignorance is always more
costly than knowledge; research is all the more
essential in difficult economic times, j5 Because
mental health problems are common to developing
and industrialized countries, knowledge can be
transferred in both directions. Priority should be
placed on strengthening the indigenous capacity for
research among colleagues in developing countries. It is imperative that we encourage nationallevel, interdisciplinary mental health policy research units and connect them with international
networks of researchers. Such international networks can serve as a clearinghouse for relevant
concepts, methods, and data. ~6
PSYCHOSOCIAL PATHOLOGY
What of psychosocial pathologies and the social
circumstances that underlie them? The 1995 report
72
LEON EISENBERG
of the World Health Organization,~7 entitled Bridging the Gaps, provides a sobering introduction to
the leading cause of mortality and morbidity:
The world's most ruthless killer and the greatest cause of
suffering on earth is . . . extreme poverty. It is the main
cause of reduced life expectancy, of handicap and disability, and of starvation. Poverty is a major contributor to
mental illness, stress, suicide, family disintegration and
substance abuse . . . . For many of the people in the world
today, every step in life, from infancy to old age, is taken
under the twin shadows of poverty and inequity and under
the double burden of suffering and disease. For many, the
prospect of a longer life may seem more like a punishment
than a prize.
The external debt of developing countries grew
15-fold over the past two decades: in 1970 it was
$100 billion, by 1980 it had increased to $650
billion, and by 1992 to more than $1,500 billion. ~8
Growing economic disparities between and within
countries fuel conflict. The gulf between the poor
and rich of the world is widening. The gap in
per-capita income between the industrial and developing world has tripled in the past 30 years. Developing countries, with 80% of the world's people,
control only 21% of the global gross national
product (GNP). Differences in economic and health
status within countries are as great or greater than
those between countries. Brazil, classified by the
World Bank 2 as an "upper-middle income country," has a per-capita GNP of $2,940; yet one in six
Brazilians subsists on less than $1 per day, and one
in three on less than $2 per day. The United States
ranks in the upper 5% of nations in average life
expectancy, but the life expectancy of black men
aged 15 to 44 years living in Harlem is lower than
that of a male Bangladeshi of the same age. 19
Of the 40 instances of armed conflict under way
this year, not one is a significant war between
states. 2° The goal is no longer the destruction of
opposing armies, but the terrorization of civilian
populations who constitute "the enemy." Such
low-intensity warfare results from the political and
economic legacies of the Cold War, from the
disintegration of state authority and the breakdown
of civil and political order, from illegitimate state
institutions, from social cleavages based on religious, cultural, or ethnic origins, inflamed by
power-seeking demagogues, and from widespread
illiteracy, poor health, political repression, and
economic deprivation in countries the world over. 2~
There are 20 million officially recognized refugees
worldwide, twice the number there were 10 years
ago; there are at least as many internally displaced
persons. Refugees and internally displaced persons
exhibit high rates of depression, anxiety disorders,
posttraumatic stress disorder, and other forms of
mental distress.
Hunger, deprivation, depression, and violence
affect women disproportionately. Women bear more
heavily the negative effects of economic restructuring on families. Selective abortion, female infanticide, differential triage of sick children in poor
families, and maternal mortality have all taken a
substantial toll on women's lives and mental health.
Sen 22 has calculated that in Southeast Asia 100
million women are missing; that is, the only viable
explanation for the high male to female ratio in the
Southeast Asian population, in contrast to the
female preponderance in the West, is the premature
death of 100 million women. Child abuse in
exploitive settings, in the commercial sex industry,
among the hundreds of thousands of street children,
in settings of ethnic and political conflict, and in
families under stress is a major source of degradation and wretchedness for millions.
Recommendations
In addition to comprehensive health policy, it
is essential to develop what Dr. Julio Frenk 23 of
Mexico calls "healthy policies." Explicit attention
must be paid to the mental health consequences of
social and economic decisions; for example, the
imposition of "structural adjustment" on the
economy of developing countries must be accompanied by corrective measures to blunt the impact on
the poor. Policies that reduce poverty, encourage
gainful employment, and provide universal basic
education, primary health care, decent housing, and
adequate nutrition are all prima facie goods. They
are not merely a concession to an abstract vision of
social justice they have tangible effects on the
health of individuals and communities.
Specific Initiatives
Coordinated efforts to improve state gender
policies, to interdict violence toward women, and to
empower women. The years of education women
receive is the single most important determinant of
their own health, the health of their children, and
that of their families. 24,25Policies that deny women
full citizenship must be fought not only because
they violate human rights, but also because they
destroy health. Women must take leadership roles
MENTAL HEALTH IN LOW-INCOME POPULATIONS
73
in g o v e r n m e n t s , i n t e r n a t i o n a l agencies, a n d n o n g o v -
r e d u c e the f r e q u e n c y o f a r m e d conflicts. P e a c e a n d
e r n m e n t a l o r g a n i z a t i o n s . L a w s to e n s u r e the p r o t e c -
security i n i t i a t i v e s m u s t target v i o l e n c e as the
tion o f w o m e n a g a i n s t d o m e s t i c v i o l e n c e , laws
m a j o r t h r e a t to social w e l l - b e i n g . M e n t a l h e a l t h
a c c o m p a n i e d b y e f f e c t i v e e n f o r c e m e n t , are f o u n d a tion efforts for m e n t a l health.
c o n c e r n s n e e d to b e m o r e w i d e l y u n d e r s t o o d in
Broad initiatives to control the causes and
consequences o f violence. O n l y f a r - r e a c h i n g
c h a n g e s in i n t e r n a t i o n a l a n d n a t i o n a l politics will
p e a c e a n d s e c u r i t y p r o g r a m s . In p r e v e n t i n g e t h n i c
conflict, the a n a l y s i s o f m e n t a l h e a l t h issues, f r o m
the effect o f r a c i s m o n i d e n t i t y to the v i c i o u s c y c l e s
o f r e v e n g e , is essential.
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