Disability and treatment of specific mental and physical disorders across the world

Background

Advocates of expanded mental health treatment assert that mentaldisorders are as disabling as physical disorders, but littleevidence supports this assertion.

Aims

To establish the disability and treatment of specific mentaland physical disorders in high-income and low- and middle-incomecountries.

Method

Community epidemiological surveys were administered in 15 countriesthrough the World Health Organization World Mental Health (WMH)Survey Initiative.

Results

Respondents in both high-income and low- and middle-income countries attributed higher disability to mental disorders than to thecommonly occurring physical disorders included in the surveys.This pattern held for all disorders and also for treated disorders.Disaggregation showed that the higher disability of mentalthan physical disorders was limited to disability in socialand personal role functioning, whereas disability in productiverole functioning was generally comparable for mental and physicaldisorders.

Conclusions

Despite often higher disability, mental disorders are under-treated compared with physical disorders in both high-income and inlow- and middle-income countries.

INTRODUCTION

TOP

INTRODUCTION

As healthcare spending continues to rise,¹ resource allocationdecisions will need to be based increasingly on informationabout prevalence, severity and chronicity of disorders andcost-effectiveness of interventions. This will require concernabout specific disorders to be based not only on informationabout prevalence and mortality, but also on disability.^2,3 Despite the fact that many studies in high-income countrieshave estimated the effects of specific disorders on disability,^4–6 comparable broad-based studies are rare in low- and middle-income countries.⁷ The aims of the current report are to determinewhether in both low- and middle-income and in high-income countriescommonly occurring mental disorders are as seriously disablingas commonly occurring physical disorders according to respondentself-reports obtained in the World Health Organization (WHO)World Mental Health (WMH) Surveys.^7,8

Methods

TOP

Methods

Sample
World Mental Health surveys were carried out in six countriesclassified by the World Bank as low- and middle-income (Colombia,Lebanon, Mexico, Peoples’ Republic of China, South Africa,Ukraine) and nine as high-income (Belgium, France, Germany,Italy, Japan, The Netherlands, New Zealand, Spain and the USA)(see online Table DS1). The total sample size was 73 441, withindividual country samples ranging from 2372 (The Netherlands)to 12 992 (New Zealand). The weighted average response ratewas 70.3%, with country-specific response rates ranging from45.9% (France) to 87.7% (Colombia). All surveys were basedon probability household samples representative of regions(in China, Colombia, Japan, and Mexico) or nationally representative(other countries).

All interviews were conducted face to face by trained lay interviewers. Each interview had two parts. All respondents completed PartI, which contained assessments of core mental disorders. AllPart I respondents who met criteria for any core mental disorderplus a probability subsample of approximately 25% of otherPart I respondents were administered Part II. The latter assessedcorrelates, service use and disorders of secondary interest. Physical disorders were assessed in Part II. The Part II datawere weighted to adjust for oversampling of people with mentaldisorders and for differential probabilities of selection withinhouseholds and to match samples to population socio-demographicdistributions.

Standardised interviewer-training procedures, WHO translationprotocols and quality control procedures were applied acrossall WMH countries to ensure comparability. These proceduresare described in more detail elsewhere.⁸ Informed consentwas obtained in all countries. Procedures for obtaining informed consent and protecting individuals were approved and monitoredfor compliance by the Institutional Review Boards of the organisationscoordinating the surveys in each country.

Measures
Physical disorders were assessed with a standard chronic disorders checklist⁹ containing ten conditions that include asthma,cancer, cardiovascular disease (hypertension, other heart disease),diabetes, musculoskeletal disorders (arthritis, chronic back/neckpain), chronic headaches, other chronic pain disorders andstomach ulcers. Respondents were asked to report whether they had had any of the symptom-based conditions (e.g. chronic headaches)in the past 12 months and to say whether a doctor had evertold them they had any of the silent conditions (e.g. hypertension)and, if so, whether they had experienced them in the past 12months.

Checklists of this sort yield more complete and accurate reportsabout chronic conditions than do open-ended questions.¹⁰ Methodologicalstudies have documented moderate to good concordance between checklist reports and medical records in high-income countries.^11–14 Comparable studies do not exist in low- and middle-income countries. Self-reports are obviously less accurate than assessments basedon biological tests. Caution is consequently needed in interpretingthe results of studies such as this one, that use self-reportto assess physical conditions. The implications of this imperfectassessment were evaluated by replicating analyses only forpeople being treated for physical disorders. People being treatedare more likely to meet full diagnostic criteria and to be more severely disabled than people who complete a self-report andwho are not being treated. A remaining bias is that the conditionsincluded in the checklist did not include the infectious diseasesthat are known to be so burdensome in low- and middle-incomecountries.

Mental disorders were assessed with version 3.0 of the WHO Composite International Diagnostic Interview (CIDI),⁸ a fully structuredlay-administered interview that generates research diagnosesof commonly occurring DSM–IV mental disorders.¹⁵ The ten disorders considered here include anxiety disorders (panicdisorder, generalised anxiety disorder, specific phobia, socialphobia, post-traumatic stress disorder), mood disorders (majordepressive disorder or dysthymia, bipolar disorder) and impulse-controldisorders (intermittent explosive disorder, adult attention-deficithyperactivity disorder, oppositional defiant disorder). Onlydisorders present in the past 12 months are considered. Generallygood concordance has been found between CIDI diagnoses of anxiety/mooddisorders and masked clinical assessment.¹⁶ Composite InternationalDiagnostic Interview diagnoses of impulse-control disordershave not been validated.

Treatment for physical disorders was assessed by asking respondentswhether they had seen a medical doctor or other health professionalin the past 12 months for the disorder. For mental disorders,disorder-specific treatment was assessed by asking each respondentwhether ‘you ever in your life talk(ed) to a medicaldoctor or other professional about (the disorder)’ and,if so, whether ‘you receive(d) professional treatmentfor (the disorder) at any time in the past 12 months’.Treatment of mental disorders was also assessed in a seriesof more general questions that asked respondents whether theyhad visited any type of professional in the past 12 months(types of professionals available varied across countries) ‘for problems with your emotions, nerves, or your use of alcoholor drugs’. Self-reports about treatment have been shownin previous methodological studies to have generally good concordancewith archival health-care utilisation records,¹⁷ although this research has been carried out exclusively in high-incomecountries.

Disability was assessed with the Sheehan Disability Scales (SDS),a widely used self-report measure of condition-specific disabilitythat, although up until now used only in the assessment ofmental disorders, can just as well be used to assess disabilitycaused by physical disorders. The SDS consists of four questions,each asking the respondent to rate on a 0–10 scale the extent to which a particular disorder ‘interfered with’activities in one of four role domains during the month inthe past year when the disorder was most severe. The four domainsare:

‘your home management, like cleaning, shopping, and takingcare of the (house/apartment)’ (home);
‘yourability to work’ (work);
‘your social life’(social);
‘your ability to form and maintain close relationshipswith other people’ (close relationships).

The 0–10 response options were presented in a visual analogueformat with labels for the response options of ‘None’(0), ‘Mild’ (1–3), ‘Moderate’(4–6), ‘Severe’ (7–9) and ‘Verysevere’ (10). A global SDS disability score was alsocreated by assigning each respondent the highest SDS domainscore reported across the four domains.

Previous methodological studies have documented good internalconsistency reliability across the SDS domains,^18,19 a resultthat we replicated in the WMH data by finding Cronbach’salpha (a measure of internal consistency reliability) in therange 0.82–0.92 across countries. Importantly, reliabilitywas high both in high-income countries (median 0.86; interquartilerange 0.84–0.88) and low- and middle-income countries(median 0.90; interquartile range 0.88–0.90). Previousmethodological studies also have documented good discrimination between role functioning of cases and controls based on SDSscores in studies of social phobia,¹⁸ panic disorder,¹⁹ post-traumaticstress disorder²⁰ and substance misuse.²¹ Similar resultswere found in the WMH surveys based on responses to a question asked after the SDS about days out of role: ‘How manydays out of 365 in the past year were you totally unable towork or carry out your normal activities because of (the illness)?’We examined the strength of SDS scores predicting variationin this relatively objective measure of disability. If theSDS measures genuine disability, we would expect correlationsto be significant and comparable for physical and mental disorders.This is, in fact, what we found. In high-income countries, the multiple correlations of the four SDS domain scores predictingdays out of role were 0.55 for mental disorders and 0.50 forphysical disorders. The comparable correlations in low- andmiddle-income countries were 0.39 for mental disorders and0.36 for physical disorders (online Table DS1).

It is important to recognise that the SDS scales are condition-specific. Respondents were asked to rate the interference to role functioningcaused by a particular disorder rather than the interferencecaused by all their health problems. This focused approachto questioning allows SDS scores to be compared across disorderswithout adjusting for comorbidity. However, this requires respondentswith multiple health problems to sort out the relative effectsof their various conditions on their overall functioning. An indication that respondents are able to do this comes fromcontrolled treatment studies that have documented significantimprovements in SDS measures of condition-specific role functioningwith treatment for generalised anxiety disorder,²² panic disorder²³ and major depression.²⁴

Because they are condition-specific, the SDS scales were administered separately for each of the ten mental disorders consideredin this report. In the case of the physical disorders, whichwere only of secondary interest in the WMH surveys, the SDSscales were administered for only one physical disorder perrespondent. This one disorder was selected randomly from among all the physical disorders reported by the respondent as beingin existence during the 12 months before interview. This methodof selection underrepresents comorbid physical disorders, whichmay be more severe than the pure (non-comorbid) disorders,as a function of the number of such disorders. In order tocorrect this bias, a weight was applied to each case equal tothe number of physical conditions reported by the respondent.

Statistical analysis
A separate observational record was created for each 12-monthphysical disorder for which SDS ratings were obtained (i.e.one for each respondent who reported one or more disorders)as well as for each 12-month mental disorder reported by eachrespondent. An otherwise average respondent who met criteria for five 12-month mental disorders and three physical disorderswould consequently be represented by six records that had asum of weights of 8.0: one record for each of the five mentaldisorders (each with a condition weight of 1.0) and a sixthrecord for a randomly selected physical disorder (with a conditionweight of 3.0).

Standard WMH respondent weights were also applied to each observational record. As noted above, these weights adjusted for differentialsampling of respondents in the Part I sample as a functionof household size and in the Part II sample as a function ofwhether or not core disorders were reported in Part I. Theseweighted records, which are representative of the conditionsin the populations, were pooled across samples for comparativeanalysis. Domain-specific and global SDS means, proportionsrated severe or very severe (henceforth referred to as severe)and the standard errors of these estimates were then calculatedseparately for each condition in each country and in more aggregatedform for all high-income and all low- and middle-income countries.

Significance tests were used to test the statistical significanceof pair-wide differences in SDS scores across all pairs ofconditions. Within-disorder comparisons were also made to determinewhether disability ratings differ in low- and middle-incomev. high-income countries. Between-disorder comparisons weremade to determine whether disability ratings are systematicallydifferent for physical disorders than mental disorders withincountries. All these analyses were then replicated using onlythe subsample of respondents being treated for physical disorders.Finally, all pair-wise comparisons were repeated on a within-personbasis: that is, by comparing SDS scores for specific pairsof conditions for the same individual (e.g. a person who hadboth depression and cancer who provided separate SDS ratingsfor these conditions). All these significance tests were adjustedfor the clustering and weighting of observations.²⁵ Significancewas consistently evaluated at the 0.05 level with two-sided tests.

Results

TOP

Results

Self-reported disorder prevalence and treatment
Despite most prevalence estimates of self-reported chronic physical disorders differing significantly between high-income and low-and middle-income countries, the broad pattern of prevalenceestimates is quite similar in the two subsamples (Table 1).Chronic back/neck pain, arthritis, chronic headaches and hypertensionare estimated to be the four most common disorders in both subsamples.Cancer, diabetes and stomach ulcers are estimated to be amongthe least common in both subsamples. Five of the ten physicaldisorders are estimated to be more prevalent in high-incomecountries and the other five more prevalent in low- and middle-incomecountries. The percentage of respondents that reported receivingtreatment for the disorders that we assessed at the time ofinterview is generally a good deal higher in high-income thanlow- and middle-income countries.

View this table:
[in this window]
[in a new window]

Table 1 12-month prevalence of disorders and treatment in high-income and low- and middle-income World Mental Health countries

The broad rank-ordering of mental disorder prevalence estimatesis also fairly similar across subsamples despite the fact that,unlike physical disorders, most mental disorders are estimatedto be significantly more prevalent in high-income than in low-and middle-income countries. Specific phobia, depression andsocial phobia are estimated to be the most prevalent disordersin both subsamples; oppositional defiant disorder and attention-deficithyperactivity disorder are estimated to be the least common. As with physical disorders, the percentage of respondents thatreported receiving treatment for the disorders that we assessedat the time of interview is consistently higher in high-incomethan in low- and middle-income countries.

The physical disorders were more likely to be treated than themental disorders. In high-income countries, 64.9% (n=6720)of all physical disorders were treated v. 23.7% (n=2637) ofall mental disorders. In low- and middle-income countries,53.2% (n=2884) of physical disorders v. only 7.7% (n=319) ofmental disorders were being treated. This pattern also holdsfor severely disabling disorders, with 77.6% (n=2172) of severephysical disorders being treated in high-income countries and64.0% (n=763) in low- and middle-income countries comparedwith 35.3% (n=1378) of severe mental disorders in high-incomecountries and 11.9% (n=145) in low- and middle-income countries.It is noteworthy that these results show the mental–physical treatment gap to be considerably higher in low- and middle-incomecountries than in high-income countries.

Individual-level disability
The physical disorders with the highest mean SDS global disabilityratings in both subsamples are chronic pain disorders, althoughbetween-disorder variation in disability ratings is much greaterin high-income than low- and middle-income countries (Table 2).Three physical disorders have significantly higher mean SDS global disability ratings in high-income countries (back/neckpain, headaches, other chronic pain disorders). Three othershave significantly higher ratings in low- and middle-incomecountries (asthma, diabetes, hypertension). A similar patternof relative disability is found for the proportion of participantsrated ‘severely’ disabled in the total sample aswell as among those being treated (online Table DS1).

View this table:
[in this window]
[in a new window]

Table 2 Disorder-specific global Sheehan Disability Scale ratings in high-income and low- and middle-income World Mental Health countries

The mental disorders with the highest mean SDS global disabilityratings in both subsamples are bipolar disorder and depression.The lowest ratings are for specific phobia. Four mental disorders(bipolar disorder, depression, generalised anxiety disorder,post-traumatic stress disorder) have significantly higher meanglobal disability ratings in high-income countries. None hasa significantly higher rating in low- and middle-income countries.A similar pattern of relative disability is found for the proportionof participants rated ‘severely’ disabled in thetotal sample as well as among those being treated (online TableDS1).

The SDS disability ratings for mental disorders are generallyhigher than for physical disorders. This is true, using Mann–Whitneytests, both for mean disability ratings (low- and middle-incomez=3.0, P=0.002; high-income z=3.0, P=0.002) and proportionsrated severely disabled (low- and middle-income z=2.5, P=0.011;high-income z=2.7, P= 0.007). Of the 100 logically possiblepair-wise disorder-specific mental/physical comparisons, meanratings are higher for the mental disorder in 91 comparisonsin high-income countries and 91 in low- and middle-income countries.Nearly all of these higher mental than physical ratings arestatistically significant at the 0.05 level. Comparable resultsare obtained for severe disability ratings and also for bothmean and severe disability ratings when we control for respondentage, gender and education, and when we focus exclusively onthe subsamples of participants being treated. (Results availablefrom the author on request.)

Consistently higher mental than physical disability ratingscan also be found in both high-income and low- and middle-incomecountries when individual SDS domains are considered insteadof global ratings (Table 3). These differences are much morepronounced for disability in social life and personal relationshipsthan in work or household management. For example, the proportionswith severe disability in work functioning associated with mental disorders in low- and middle-income and high-income countries (19.4–21.7%, n=673–2135) are only slightly higherthan the proportions associated with physical disorders (17.9–18.1%, n=874–2028). The proportions with severe disability insocial functioning associated with mental disorders (21.8–28.0%, n=775–2758), in comparison, are dramatically higher thanthose associated with physical disorders (10.3–8.9%, n=513–1168). Similar patterns of mental/physical differences are found when we compare mean disability ratings rather thanthe proportions rated as severe and when we compare both meansand proportions rated as severe among people being treated(see online Table DS1). In addition, an attenuated versionof the same general pattern holds when we compare people beingtreated for physical disorders to all (i.e. being treated ornot) mental disorders to address the concern that the moresuperficial assessment of physical than mental disorders mighthave resulted in the inclusion of a sub-threshold of individualswith physical disorders who might have low disability (online Table DS1).

View this table:
[in this window]
[in a new window]

Table 3 Sheehan Disability Scale global and domain-specific ratings (proportion rated severely disabled) aggregated across physical (total and treated) and mental (total) disorders in high-income and low- and middle-income World Mental Health countries

Discussion

TOP

Discussion

Four key findings emerged from the analyses. First, respondentsgenerally attributed more disability to their mental ratherthan physical disorder. Second, the higher disability of mentalcompared with physical disorders held as strongly in low- andmiddle-income countries as in high-income countries. Third,the higher aggregate disability of mental than physical disorderwas much more pronounced for disability in social and personalrelationships than in productive (work and housework) roles.Fourth, the proportion of participants receiving treatmentat the time of interview was much lower for mental than physicaldisorders in high-income countries and even more so in low-and middle-income countries both in the total sample and whenwe focused exclusively on participants rated as having a severelydisabling disorder. These findings substantially extend theresults of previous studies, none of which documented comparabilityin the disabilities associated with such a varied set of physicaland mental disorders, or disaggregated disability into thedomains considered here to detect the greater relative impactof mental v. physical disorders in social/personal domainscompared with productive role domains.^2,4–7

These results are limited by a number of sampling and measurementproblems. With regard to sampling, results could be influencedby a truncation of the severity spectrum of physical disorders.For example, persons facing the end stage of a chronic physicaldisease might be institutionalised or not willing or able toparticipate in an interview to a greater extent than peoplewith severe mental disorders, leading to under-estimation ofthe relative disability of physical compared with mental disorders.Whether such a difference in sample bias actually exists, though,is unknown.

Limitations
There were a number of measurement problems in the analysis.One is that the physical conditions checklist did not includethe infectious diseases that play such an important part inmorbidity in low- and middle-income countries. Our resultsconsequently can be generalised only to chronic cardiovascular, digestive, metabolic, musculoskeletal, pain and respiratoryconditions. However, the conditions considered are importantsources of morbidity even in low- and middle-income countriesand the results are consequently relevant to those countriesdespite the exclusion of infectious diseases.

Another measurement problem is that the physical disorders wereassessed by a simple self-report rather than by abstractingmedical records or administering medical examinations. Mentaldisorders were assessed more comprehensively with a fully structuredlay-administered diagnostic interview. The more superficialassessment of physical disorders might have led to the inclusionof more individuals with sub-threshold physical disorders thanthose with sub-threshold mental disorders, introducing an artificiallowering of the estimated disability of physical disorders,although we addressed this in our analysis of treated physicalconditions. It might also have led to artificial overlap betweenthe assessments of mental and physical disorders to the extent that core symptoms of some physical conditions (e.g. headache,unexplained chronic pain) are markers of underlying mentaldisorders, although this would have attenuated physical/mentaldifferences by increasing overlap between the two classes ofdisorders. In addition, the use of a self-report checklist almostcertainly led to an under-estimation of undiagnosed silent physical conditions. As the latter are likely to be less disabling thansymptom-based conditions or diagnosed silent conditions, thisbias presumably led to an artificial increase in the estimateddisability of physical disorders.

Some of the WMH physical disorder prevalence estimates are lowerthan those in gold-standard assessments. For example, the populationprevalence of diabetes has been assessed in a number of communitysurveys using glucose tolerance tests on blood samples.²⁶A meta-analysis of these studies suggests that the prevalenceof diabetes is highest in North America (9.2%) and Europe (8.4%),lower in India and most of Latin America (5–8%), andlowest in most of Africa and China (2–5%).²⁷ The WMHprevalence estimates, 4.6% in high-income countries and 3.9%in low- and middle-income countries, are lower than these gold-standardestimates, presumably reflecting the fact that the latter includeundiagnosed cases.

In other instances the WMH prevalence estimates are higher thanthose in gold-standard assessments. For example, cancer prevalencedata have been assembled from various administrative databasesand registries in a number of countries.²⁸ Meta-analysis ofthese data suggest that cancer is more common in high-income than low- and middle-income countries, with the highest prevalencein North American (1.5% of the population aged 15 and olderdiagnosed within the past 5 years), followed by Western Europe(1.2%), Australia and New Zealand (1.1%), Japan (1.0%), EasternEurope (0.7%), Latin America and the Caribbean (0.4%), witha much lower estimated prevalence in the rest of the world (0.2%).The much higher cancer prevalence estimates in the WMH data,4.0% in high-income countries and 0.6% in low- and middle-incomecountries, presumably reflect the fact that cancer survivorswho were diagnosed and treated more than 5 years ago, althoughnot counted in cancer prevalence estimates because they havethe same survival rates as the general population, often considerthemselves still to have cancer and report this in communitysurveys.

Based on comparisons such as these with gold-standard assessments,caution is needed in interpreting the WMH prevalence estimatesof physical disorders. However, the fact that the same generalpattern of higher disability among mental disorders comparedwith physical disorders held in comparisons of individualstreated for physical disorders argues strongly that the findingof higher SDS disability associated with mental than with physicaldisorders is not due to imprecision in the measurement of physicaldisorders.

Another measurement problem involves the fact that disabilitywas assessed with brief self-report scales rather than clinicalevaluations. This might have introduced upward bias in thereported disability caused by mental disorders compared withphysical disorders to the extent that people with mental disordersgave overly pessimistic appraisals of their functioning. This would seem to be an unlikely interpretation, though, in thatthe associations of SDS ratings with reported numbers of daysout of role – a more objective indicator of disabilitythan the SDS ratings – were found to be equivalent formental and physical disorders. Furthermore, within-person comparison,which controlled for individual differences in perceptions,found similar results.

Another possibility is that the SDS questions might have beenbiased in the direction of assessing the disabilities associatedwith mental more than physical disorders. This would seem unlikely,though, as the SDS questions are quite broad and cover allthe main areas of adult role functioning. Another possiblelimitation is that the SDS focused on the ‘worst month’ in the past year, introducing recall error that possibly wasmore extreme for physical disorders than mental disorders.In addition, between-disorder differences in persistence werenot taken into consideration, which means that particular disordersmight have been more dominant in severity ratings than suggestedhere if they were more persistently severe than others. The aggregate disability estimates should be interpreted cautiouslybecause of these limitations regarding the recall period.

A final measurement problem concerning the assessment of disabilityrelates to our use of a condition-specific measurement approach.This is an attractive approach from a statistical perspective,compared with an unconditional measurement approach (i.e. anapproach that simply assesses overall disability without askingthe respondent to make inferences about the conditions that caused the disability), because it produces condition-specificestimates directly, avoiding the need to rely on multivariateequations that adjust for the effects of comorbidity in predictingoverall disability. However, this advantage in analytic simplicityis achieved by requiring respondents with comorbid conditionsto perform the difficult task of making judgements about theeffects of individual conditions on their functioning. Becauseof likely imprecision in these assessments, it would be usefulto replicate the results reported here in multivariate analysesthat evaluate the separate and joint effects of comorbid conditionsin predicting an unconditional measure of disability. Unfortunately,the statistical methods needed to estimate models of this sortare very complex,²⁹ making it difficult to carry out suchanalyses.

Burden of illness and likelihood of treatment
Within the context of these limitations, the results reportedhere are consistent with previous comparative burden-of-illnessstudies in suggesting that musculoskeletal disorders and majordepression are the disorders with the largest contributionto disability at the individual level both in high-income andin low- and middle-income countries. Previous studies have documentedthis pattern only for the USA,^30–32 although the importanceof depression has also been documented throughout the worldin the World Health Surveys.⁷ The current report replicatesthe World Health Surveys results regarding depression and documentsfor the first time the cross-national importance of musculoskeletaldisorders. As noted above, the WMH results also suggest that mental disorders are especially disabling to personal relationshipsand social life, which implies that they are disabling morebecause they create psychological barriers rather than physicalbarriers to functioning. Among these barriers are limitationsin cognitive and motivational capacities, affect regulation,embarrassment and stigma,³³ and a tendency to amplify physical symptoms³⁴ andassociateddisability.³⁵

Given this greater disability of mental than physical disorders,it is disturbing to find that only a minority of people withsevere mental disorders receive treatment and that treatmentis substantially more common for comparably severe physicaldisorders. In high-income countries, seriously disabling mentaldisorders are only about half as likely to be treated as seriouslydisabling physical disorders (35.3% v. 77.6%), and only about20% as likely to be treated compared with severe physical disordersin low- and middle-income countries (11.9% v. 64.0%). Thislow treatment rate is consistent with the low rate of recognitionand treatment of mental disorders in primary care, especiallyif comorbid with physical disorders.^36,37 Combined with theburden of disability that mental disorders produce, the low treatment rates call for more attention to mental disorders.

Implications of the WMH findings for treatment are not clearbecause, even though treatment effectiveness trials documentthat common anxiety and mood disorders can often be successfully treated,^38,39 uncertainties exist regarding long-term outcomes.Another limitation of existing trials is that they focusedon symptoms and did little to assess the effects of treatmenton reducing disability.^38,39 In particular, long-term functionaloutcomes are important to track because residual disabilityand recurrence of disability are major problems with chronicmental disorders.⁴⁰ Despite this uncertainty about long-termoutcomes, the results reported here argue strongly that, onthe basis of population disease burden associated with disorder-specificdisability, more attention should be given to the treatment of mental disorders and that this is especially so in low-and middle-income countries.

ACKNOWLEDGMENTS

TOP

ACKNOWLEDGMENTS

The surveys included in this report were carried out in conjunctionwith the World Health Organization (WHO) World Mental Health(WMH) Survey Initiative. We thank the WMH staff for assistancewith instrumentation, fieldwork and data analysis. These activitieswere supported by the US National Institute of Mental Health(NIMH; R01-MH070884), the John D. and Catherine T. MacArthurFoundation, the Pfizer Foundation, the US Public Health Service(R13-MH066849, R01-MH069864 and R01 DA016558), the Fogarty InternationalCenter (FIRCA R01-TW006481), the Pan American Health Organization(PAHO), Eli Lilly, Ortho-McNeil Pharmaceutical, Inc., GlaxoSmithKline,and Bristol-Myers Squibb. A complete list of WMH publications can be found at www.hcp.med.harvard.edu/wmh/. The MexicanNational Comorbidity Survey is supported by The National Institute of Psychiatry Ramon de la Fuente (INPRFMDIES 4280) and by theNational Council on Science and Technology (CONACyT-G30544-H),with supplemental support from PAHO. The Lebanese survey issupported by the Lebanese Ministry of Public Health, the WHO(Lebanon) and unrestricted grants from Janssen Cilag, Eli Lilly,GlaxoSmithKline, Roche, Novartis, Fogerty (R03-TW0006481) andanonymous donations. The European Study of the Epidemiologyof Mental Disorders project was funded by the European Commission(Contracts QLG5-1999-01042; SANCO 2004123), the Piedmont Region(Italy), Fondo de Investigación Sanitaria, Institutode Salud Carlos III, Spain (FIS 00/0028), Ministerio de Cienciay Tecnología, Spain (SAF 2000-158-CE), Departament deSalut, Generalitat de Catalunya, Spain, other local agenciesand by an unrestricted educational grant from GlaxoSmithKline.The Chinese World Mental Health Survey Initiative is supportedby the Pfizer Foundation. The Colombian National Study of MentalHealth is supported by the Ministry of Social Protection, with supplemental support from the Saldarriaga Concha Foundation.The World Mental Health Japan Survey is supported by the Grantfor Research on Psychiatric and Neurological Diseases and MentalHealth (H13-SHOGAI-023, H14-TOKUBETSU-026, H16-KOKORO-013)from the Japan Ministry of Health, Labour and Welfare. The New Zealand Mental Health Survey is supported by the New ZealandMinistry of Health, Alcohol Advisory Council, and the HealthResearch Council. The South Africa Stress and Health Studyis supported by the NIMH (R01-MH059575) and National Instituteof Drug Abuse (NIDA) with supplemental funding from the SouthAfrican Department of Health and the University of Michigan(NIMH: HHSN271200700030C). The Ukraine Comorbid Mental Disordersduring Periods of Social Disruption study is funded by theNIMH (R01-MH61905). The US National Comorbidity Survey Replicationis supported by the NIMH (U01-MH60220 with supplemental supportfrom NIDA, the Substance Abuse and Mental Health Services Administration,the Robert Wood Johnson Foundation (Grant 044780), and the JohnW. Alden Trust.

REFERENCES

TOP