The Burden of Mental Disorders in the Region of the Americas, 2018

Washington, DC 2018 Also published in Spanish La carga de los trastornos mentales en la Región de las Américas, 2018 ISBN: 9789275320280

The Burden of Mental Disorders in the Region of the Americas, 2018 ISBN: 9789275120286

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Foreword vii Acknowledgments viii List of acronyms ix Main findings x Introduction 1 Disease burden distribution in the Americas 3 Regional disability and mortality: disability-adjusted life years (DALYs) 4 Regional disability: years lived with disability (YLDs) 4 Country-level analysis 5 Country-level disability and mortality (DALYs) 7 Country-level disability (YLDs) 7 Common mental disorders 11 Disability resulting from specific disorders 11 Depressive disorders 12 Anxiety disorders 13 Self-harm and suicide 14 Somatoform disorders/persistent somatoform pain disorder 15 Severe mental disorders 17 Schizophrenia 17 Bipolar disorders 17 Substance use and eating disorders 18 Disorders due to use of alcohol 18 Disorders due to substance use (not alcohol) 19 Eating disorders 20 Disorders with onset usually occurring in childhood and adolescence 21 Neurological disorders 22 Neurocognitive disorders 22 Epilepsy 22 Migraine and tension-type headaches 23 Health system response in the Americas: Government funding for mental health services 25 Mental health spending as a percentage of government health spending 26 Mental health spending allocation 27 Conclusion 31 References 33 Annex 1. Non-Latin Caribbean Subregion Countries and Population 35 List of Figures

Figure 1: Regional disability-adjusted life years (DALYs) distribution tree map (%) 4 Figure 2: Ranked mental, neurological, disorders due to substance use, and suicide DALYs 5 Figure 3: Regional years lived with disability (YLD) distribution (%) 6 Figure 4: Ranked mental, neurological, disorders due to substance use, and suicide years lived with disability (YLDs) 6 Figure 5: Population distribution of the countries in the Americas 7 Figure 6: Disability-adjusted life years (DALYs) distribution by country (%) 8 Figure 7: Years lived with disability (YLDs) by country (% of total YLDs) 9 Figure 8: Mental, neurological, disorders due to substance use and suicide disability tree map (YLDs by country as a percentage of total disability) 10 Figure 9: Depressive disorder disability tree map (YLDs by country as a percentage of total disability) 12 Figure 10: Depressive disorder: years lived with disability by age groups (total of YLDs) 13 Figure 11: Anxiety disorders disability tree map (YLDs by country as a percentage of total disability) 14 Figure 12: Suicide and self-harm burden tree map (DALYs by country as a percentage of total disability) 15 Figure 13: Total years of life lost by age group 16 Figure 14: Schizophrenia disability tree map (YLDs by country as a percentage of total disability) 18 Figure 15: Bipolar affective disorder disability tree map (YLDs by country as a percentage of total disability) 19 Figure 16: Disorders due to use of alcohol disability tree map (YLDs by country as a percentage of total disability) 20 Figure 17: Disorders due to substance use (not alcohol) disability tree map (YLDs by country as a percentage of total disability) 21 Figure 18: Disorders with onset usually occurring in childhood and adolescence disability tree map 22 Figure 19: Dementia disability tree map 23 Figure 20: Epilepsy disability tree map 24 Figure 21: Mental health spending vs. per-capita GDP (PPP) 27 Figure 22: Ratio of % of total DALYs attributable to MNSS to % of health spending allocated to mental health, ordered from smallest to largest 28 Figure 23: MNSS spending allocated to mental hospitals vs. GDP (PPP) 29 Figure 24: Imbalance in spending: ratio of MNSS burden to efficiently allocated spending 30 Foreword

This report aims to improve the assessment of mental health needs in the Americas by providing an updated and nuanced picture of: (a) the disability resulting from mental, substance use, and specific neurological disorders, plus self-harm, alone and in combination with premature mortality; (b) the imbalance between mental health spending and its related disease burden; and (c) the inadequate allocation of the meager mental health spending by countries of the Region.

Consistent with global trends, the epidemiologic transition in the Americas has resulted in a shift from communicable diseases, nutritional deficiencies, and maternal and child health conditions being the major causes of ill health and death, to noncommunicable diseases, which are responsible for increasingly higher levels of disability and premature mortality. A substantial proportion of the health problems in the Americas also arise from mental, neurological, and substance use disorders. Data show that people with mental disorders have high levels of disability as well as high mortality rates.

The Global Burden of Disease (GBD) approach is a systematic, scientific process to quantify the comparative magnitude of health lost due to diseases, injuries, and risk factors by age, sex and geography, for specific time periods. The GBD has had a profound impact on health policy as it is able to reveal the hidden burden of mental illness around the world.

The Burden of Mental Disorders in the Region of Americas, 2018 documents the latest available estimates of the burden of these conditions at the regional level. The data also reveal the consequences of these disorders in terms of lost health. Furthermore, this report provides data that demonstrate the limited resources within countries to adequately meet mental health needs, while underlining the often inequitable distribution and inefficient uses of such resources.

This report seeks to inform governments, civil society, and other stakeholders, and in so doing, raise the level of awareness about mental disorders in the Region, so as to mobilize political will and the necessary resources to combat mental, neurological, and substance use disorders and suicide in the Americas.

Dr. Anselm Hennis Director Department of Noncommunicable Diseases and Mental Health Pan American Health Organization

The Burden of Mental Disorders in the Region of the Americas, 2018 vii Acknowledgments

The Mental Health and Substance Use Unit of the Pan American Health Organization (PAHO/WHO) wishes to express its sincere thanks to all who diligently collaborated during the development and implementation of this research. This assessment of mental health needs in the Americas takes into account information from various sources concerning the burden related to mental, neurological, substance use, and suicide as well as government spending. This report would not have been possible without these contributions.

Dr. Daniel Vigo (Centre for Applied Research in Mental Health and Addictions, Simon Fraser University; Department of Global Health and Social Medicine, Harvard Medical School) was responsible for collecting and analyzing data and was the principal author of the text. Mrs. Dévora Kestel (PAHO) coordinated the production of this report, supervised its content, and was responsible for writing sections of the text. Dr. Anselm Hennis (PAHO) contributed to the review process of the report. Dr. Jorge Rodriguez (Consultant) and Dr. Wendel Abel (University of the West Indies) provided valuable peer review comments. Dr. Matías Irarrázaval (PAHO) participated in the review process of the report and was responsible for writing some sections of the text along with Drs. Andrea Bruni (PAHO), Claudina Cayetano (PAHO), and Carmen Martinez (PAHO). Drs. Arthur Kleinman, Graham Thornicroft, Rifat Atun, and Anne Becker provided invaluable input to the principal author of this report.

viii The Burden of Mental Disorders in the Region of the Americas, 2018 List of Acronyms

DALYs Disability-adjusted life years

DSM Diagnostic and Statistical Manual of Mental Disorders

GBD Global Burden of Disease

GDP Gross domestic product

ICD International Classification of Diseases

LAMICS Low- and middle-income countries mhGAP Mental Health Gap Action Programme

MNSS Mental, neurological, substance use, and suicide

NCDs Noncommunicable diseases

PAHO Pan American Health Organization

PPP Purchasing power parity

WHO World Health Organization

WHO-AIMS World Health Organization Assessment Instrument for Mental Health Systems

YLDs Years lived with disability

YLLs Years of life lost

The Burden of Mental Disorders in the Region of the Americas, 2018 ix Main Findings

zzMental, substance use, and specific neurological disorders and suicide form a subgroup of diseases and conditions that are a major cause of disability and mortality, and give rise to a third of total years lived with disability (YLDs) and a fifth of total disability-adjusted life years (DALYs) in the Americas. zzDepressive disorders are the largest cause of disability alone, and combined with mortality, account for 3.4% of total DALYs and 7.8% of total YLDs. zzThe second largest subset comprises anxiety disorders, with 2.1% and 4.9%, respectively, of total DALYs and YLDs. Self-harm and somatoform disorders with prominent pain account, respectively, for 1.6% of DALYs and 4.7% of YLDs. zzSouth America, in general, has higher proportions of disability due to common mental illness. Central America has a larger proportion of disability due to bipolar and childhood onset disorders, as well as due to epilepsy, than other subregions; and the USA and Canada suffer a high toll of disability from schizophrenia and dementia, as well as from devastating rates of opioid-use disorder. zzThe health system’s response to the challenge of mental illness shows a correlation with national income. Higher- income countries spend a larger share of their health budgets on mental health services, and appear to allocate their spending more efficiently, away from neuropsychiatric hospitals and based on integration of mental health into primary care and community-based resources. Conversely, lower-income settings seem to compound their lack of resources by allocating them to specialized neuropsychiatric hospitals instead of funding community-based mental health services. zzThe imbalance between the percentage of the total burden caused by mental disorders, and the percentage of total health expenditures effectively allocated to mental health leads to the burden being three times the spending in the high-income countries to 435 times the spending in lowest-income country, with a regional median of 34. zzDespite the constraints affecting mental health budgets in the Americas, there is significant potential to make meaningful improvements, while prioritizing the funding of community-based mental health services.

x The Burden of Mental Disorders in the Region of the Americas, 2018 Introduction dominated by noncommunicable diseases (NCDs), multimorbidity, and survival with disability (9,10). Within this The global mental health field is rapidly evolving, particularly landscape, mental illness is proving to be a particularly since the early 2000s, thanks to the collaboration of complex challenge: despite its increasing visibility in the multilateral organizations, academic partners, patient global health and development community, pervasive and user advocates, and mental health workers. This structural stigma, outdated frameworks and practices, and joint effort yielded milestones such as the World Mental organizational fragmentation affect the ability to adequately Health Report, the mhGAP program, the Lancet Global assess, prioritize, invest in, and respond to mental illness in Mental Health series, the Mental Health Movement, and proportion to burden, in parity with physical health, and in other initiatives that led to a better understanding of the keeping with effectiveness and cost-effectiveness evidence. disease burden of mental illness and of what the evidence- based response to it should be (1–3). Mental illness is An adequate needs assessment is the cornerstone of increasingly acknowledged as a global health priority, prioritization, sound investment, and appropriate response, and given its economic burden it is also beginning to be and traditional assessments of mental illness burden have considered a global development priority (4–6). Ultimately, methodological constraints that result in an underestimation this emergent prioritization led to its inclusion in the of mental illness due mainly to five reasons: (i) the arbitrary Sustainable Development Goals and to a global consensus separation between psychiatric and neurological disorders; that the drive for universal health coverage should be (ii) the consideration of suicide and self-injurious behavior as inclusive of mental health and well-being (7,8). a separate category outside mental illness; (iii) the conflation of painful somatoform disorders with musculoskeletal The epidemiologic transition is transforming the world: disorders; (iv) the exclusion of personality disorders; and (v) global health needs used to be determined by communicable the inadequate consideration of the contribution of severe diseases and early mortality, whereas now they are largely mental illness to mortality from associated causes.

The Burden of Mental Disorders in the Region of the Americas, 2018 1 An additional caveat is the fact that the disease burden varies Panel 1. regionally and across time, so for burden estimations to be valid they need to be updated. It is a well-established fact Tree mapping. that the disease burden profile differs between low-, middle-, and high-income countries; urban and rural populations; Throughout this report, tree maps will be used to convey low- and high-income households; men and women; and multidimensional information in a single visualization. across different age groups. Though it is not scientifically Tree maps display data through nested rectangles, with possible to address all these determinants simultaneously, each rectangle having three dimensions: color, size, and each assessment of need must explicitly define its scope, position. and its validity limitations, both internal and external.

The difference in colors within each tree map indicates This report aims at improving the assessment of mental the four PAHO subregions (Latin America, the Non-Latin health needs in the Americas by providing an updated and Caribbean, South America, and Canada and the United nuanced picture of: (a) the disability resulting from mental, States). Figure 5 shows each subregion in a different substance use, and specific neurological disorders, plus self- color, but the other tree maps in this report will use harm, alone and in combination with premature mortality; different shades of the same color to identify the four (b) the imbalance between mental health spending and its subregions, from lightest to darkest. related disease burden; and (c) the inadequate allocation of the meager mental health spending. The goal is to present: The difference in size reflects the quantitative difference 1. A regional population-level view of mental disorders in the between each country. Figure 5 shows the difference in context of an overall health perspective, understanding the number of people, while the other tree maps reflect how the disease burden varies between subregions and the different magnitude of the disease burden for each from country to country, particularly in relation to the country. other NCDs; to the communicable, maternal, nutritional, The position depends on the size, with the largest and neonatal conditions; and to injuries. rectangles on the upper-left corner and the smallest in 2. A detailed analysis of the burden related to mental, the lower-right corner. It is useful to see all countries with neurological, substance use, and suicide (MNSS) at a similar size—hence a similar disease burden—clustered the continental level and by country, specifying the together in the same region of the tree map. percentage of the total disease burden that is due to the different mental disorders in terms of disability and So, at a glance we can see which countries have the combined with premature mortality. largest and the smallest disease burden, by the size of 3. A mapping of how the most relevant mental disorders the rectangles; whether countries belong to the same are distributed across the Americas, considering how subregion, hence of the same color; whether countries the different countries and subregions are affected. share a similar burden or not, if they are clustered or 4. An analysis of how government spending in mental dispersed in the graph; and whether there are sub- health varies across the Americas in relation to national regional gradients, indicated by the existence of well- income, with a focus on mental health spending as a defined color clusters. fraction of total government health spending, and on the percentage of mental health spending allocated to Each tree map will have a color cue and a brief description psychiatric hospitals. of its dimensions and what they represent. 5. Finally, simple and intuitive metrics are proposed in order to best assess the gap between disease burden and effective government spending on mental health.

2 The Burden of Mental Disorders in the Region of the Americas, 2018 Disease burden distribution in the Americas

Since the publication in 1996 of the seminal work on the Years of life lost (YLLs) provide a measure of cause- Global Burden of Disease (GBD), and through the sustained specific mortality weighted by life expectancy at time of work by the World Health Organization and the Institute of death. Health Metrics and Evaluation, the disease burden metrics provide actionable, quantitative outcomes to measure Years lived with disability (YLDs) provide a measure of and compare the disability and mortality that different a disease’s prevalence weighted by its disabling impact. illnesses impose upon individuals and communities (11–13). Estimating the local, national, and regional disease burden We extracted 2015 disaggregated data (country-age- allows for rational disease prioritization, resource allocation, sex-specific absolute numbers, rates, and percentages) and health system planning—in conjunction with other from the Global Health Data Exchange for all disease causes criteria such as the broader social and economic burden, and countries in the Americas, and re-estimated the disease ethical considerations, and local resources or preferences. burden for MNSS following the framework described by Vigo et al., which includes: (a) self-harm-related disability In gathering and analyzing the data, it is important to and mortality; (b) neurological conditions with prominent understand the following three metrics: mental and behavioral syndromes that present frequently at the primary care level (dementia, epilepsy, migraine, Disability-adjusted life years (DALYs) provide a and tension-type headache); and (c) a fraction of pain composite measure of the mortality and disability syndromes without anatomic correlation, corresponding to attributable to any given illness. an estimation for DSM-5 somatic symptom disorder with

The Burden of Mental Disorders in the Region of the Americas, 2018 3 prominent pain and ICD-10 somatization disorders, which subgroup cause of disease burden in terms of disability frequently constitute a presentation of mood, anxiety, and and mortality combined, even larger than two higher level personality disorders, particularly in contexts of high stigma groupings: injuries and communicable, maternal, child, towards common mental illness (12,13,15,16). and nutritional disorders.

Figure 1 shows the three groups of disorders (NCDs; Regional disability and communicable, maternal, child, and nutritional disorders; mortality: disability-adjusted and injuries) with MNSS as a separate subgroup of NCDs. The largest mental cause of DALYs is depressive disorders, life years (DALYs) which account for 3.4% of total DALYs, followed by anxiety disorders with 2.1%. A regional ranking of specific mental Globally, NCDs accounted for 60% of total DALYs in 2015, disorder DALYs is available in Figure 2. of which 12% corresponded to MNSS. Meanwhile in the Americas, NCDs accounted for a much larger 78% of total DALYs, with MNSS taking up a much larger fraction of DALYs Regional disability: years lived at 19%. The remaining 59% of NCD DALYs are distributed with disability (YLDs) among cardiovascular disease; cancer; musculoskeletal disorders; diabetes; neurologic, respiratory, digestive, urinary, gynecologic disorders, and others. Finally, Mortality data do not adequately capture the deaths communicable, maternal, child, and nutritional disorders caused by mental illness; therefore, it is useful to are responsible for 12%, and injuries for 10% of total DALYs. compare disability separately, as measured by YLDs. This distribution highlights the fact that MNSS comprise This metric is not affected by the exclusion of mental nearly a fifth of total DALYs, constituting the largest illness deaths and provides a valid comparison across

Figure 1: Regional disability-adjusted life years (DALYs) distribution tree map (%)

19% 12% Communicable, 59% mother, child and nutritional MNSS disorders

Noncommunicable diseases Injuries 10%

4 The Burden of Mental Disorders in the Region of the Americas, 2018 disease groupings. Our analysis shows that MNSS report—of very dissimilar population numbers. Figure 5 account for more than a third of total disability in the shows a tree map of all countries grouped by subregions, Americas: 34% of total YLDs. with the size of each square reflecting the population size. It is clearly seen that three countries—the United All the other NCD sub-groups combined account for an States, Brazil, and Mexico—comprise two-thirds of the additional 54% of YLDs; communicable, maternal, child and billion people living in the Americas, so the aggregated nutritional for 8% of disability; and injuries for 4%, making regional disease burden will be highly determined by the MNSS by far the largest subgroup (Figure 3). Figure 4 disease profile of these three countries. Furthermore, shows a regional ranking of YLDs attributable to MNSS. an exclusively regional perspective would obscure the disease burden of the Non-Latin Caribbean, given their comparatively small populations (the green fraction of Country-level analysis Figure 5). Besides the country-specific percentages, average country-level percentages will be provided when In order to complement the regional analysis, a by-country meaningfully different from the regional aggregate. study of the disease burden of mental disorders was conducted. This detailed country-level grounding of the (b) The goal of this report is to provide an actionable data is important because of two main reasons: needs assessment that can inform mental health prioritization, system planning, and service delivery at (a) The Americas comprise a vast number of countries the country level, so it is with national-level decision- and territories—36 of which have been included in this makers in mind that this report has been conceived.

Figure 2: Ranking of mental, neurological, and substance use disorders, and suicide DALYs

Depression 3.35% Anxiety disorders 2.10% Pain disorders 2.04% Neurocognitive disorders 1.95% Migraine 1.86% Self harm 1.62% Substance use disorders 1.46% Schizophrenia 0.86% Alcohol use disorders 0.80% Bipolar disorder 0.59% Autism 0.52% Other 0.51% Epilepsy 0.49% Conduct disorder 0.32% Eating disorders 0.13% Tension-type headache 0.12% Intellectual disability 0.10% Attention-deficit disorders 0.04% 0.000 0.005 0.010 0.015 0.020 0.025 0.030 0.035 % of total DALYs

The Burden of Mental Disorders in the Region of the Americas, 2018 5 Figure 3: Regional years lived with disability (YLD) distribution (%) 34% 54% MNSS 8% 4% Communicable, maternal, Noncommunicable diseases child and nutritional disorders Injuries

Figure 4: Ranking of mental, neurological, and substance use disorders, and suicide years lived with disability (YLDs)

Depression 7.84% Anxiety disorders 4.92% Pain disorders 4.71% Migraine 4.36% Schizophrenia 1.97% Substance use disorders 1.84% Bipolar disorder 1.37% Autism 1.21% Other 1.20% Neurocognitive disorders 1.19% Alcohol use disorders 0.94% Epilepsy 0.75% Conduct disorder 0.75% Eating disorders 0.29% Tension-type headache 0.27% Intellectual disability 0.23% Attention deficit disorders 0.08% Self-harm 0.05% 0.00 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 % of total YLDs

6 The Burden of Mental Disorders in the Region of the Americas, 2018 Figure 5: Population distribution of the countries in the Americas

Brazil Colombia Peru Venezuela Mexico 207,846,953 48,263,936 31,393,214 31,105,673 127,042,701

Argentina Chile Bolivia Canada and US 43,413,241 17,948,052 10,766,601 Latin Central America Non-Latin Caribbean Paraguay Ecuador 6,652,900 South America 16,154,094 Uruguay 3,434,235

United States Canada Guatemala 323,526,036 36,145,518 Cuba Haiti 16,355,051 11,392,676 10,721,459

Dominican Republic 10,529,766 El Salvador 6,137,389 Nicaragua 6,088,617 Rica Costa 4,808,814 Honduras 8,096,450 Panama Puerto Rico 3,928,551 3,683,846

Non-Latin Caribbean countries (those colored green) and their populations are listed in Annex 1.

Country-level disability and despite large individual variations, whereas the group of mortality (DALYs) communicable, maternal, child, and nutritional disorders and the group of injuries alternate in the second and third rank-order, with a primacy of the former, especially in lower- There is significant heterogeneity in the distribution of the income countries. The subgroup of MNSS also shows large main causes of disability combined with mortality in the between-country variation, ranging from 9% of total DALYs Americas. DALYs caused by NCDs, including mental illness, in Haiti to 23% in Canada (see Figure 6). are the largest fraction of total burden in every country in the Region of the Americas, ranging from 50% in Haiti to 89% of total burden in Canada. The second regional cause- Country-level disability (YLDs) group of DALYs, comprising communicable, maternal, child, and nutritional disorders, ranges between 5.5% in Canada An analysis of years lived with disability (YLDs) provides and the United States and 39% in Haiti. The third regional a picture that (a) complements the DALY burden analysis cause of DALYs is the group of injuries, which ranges from and (b) is not biased by the differential exclusion of excess 6% in Canada, Cuba, Barbados and Bermuda, to 20% in El mortality resulting from mental illness. The between- Salvador. Figure 6 highlights that NCDs remain the largest country variation of YLDs as a percentage of total disability cause of disability and mortality combined across countries is much lower than the DALY variation discussed in the

The Burden of Mental Disorders in the Region of the Americas, 2018 7 Figure 6: Disability-adjusted life years (DALYs) distribution by country (%)

Canada 23% United States 22% Chile 21% Costa Rica 21% Nicaragua 19% Peru 19% Bermuda 19% Colombia 18% Cuba 18% Puerto Rico 18% Brazil 17% Antigua and Barbuda 17% Uruguay 17% El Salvador 17% Paraguay 17% Argentina 17% Ecuador 17% Panama 17% Mexico 16% Suriname 16% Saint Lucia 16% Dominican Republic 15% Honduras 14% Belize 14% Bolivia 14% Venezuela 14% Trinidad and Tobago 14% Guatemala 14% Dominica 14% Barbados 14% Jamaica 14% Saint Vincent and the Grenadines 14% Grenada 14% Virgin Islands, U.S. 14% Guyana 13% Haiti 9% MNSS 0% 20% 40% 60% 80% 100% Noncommunicable diseases Injuries Communicable, maternal, neonatal, and nutritional diseases

8 The Burden of Mental Disorders in the Region of the Americas, 2018 Figure 7: Years lived with disability (YLDs) by country (% of total YLDs)

Brazil 36% Chile 36% Paraguay 36% Peru 35% Colombia 35% Nicaragua 35% Costa Rica 34% Argentina 34% Honduras 34% Mexico 33% United States 33% Ecuador 33% Belize 33% Antigua and Barbuda 33% Bermuda 33% Dominican Republic 33% Uruguay 33% Canada 33% Suriname 32% Panama 32% Bolivia 32% Saint Lucia 32% Saint Vincent and the Grenadines 32% Grenada 32% Guatemala 32% El Salvador 32% Cuba 32% Puerto Rico 31% Dominica 31% Jamaica 31% Trinidad and Tobago 31% Guyana 31% Barbados 30% Virgin Islands, U.S. 30% Venezuela 29% Haiti 28% MNSS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Noncommunicable diseases Injuries Communicable, maternal, neonatal, and nutritional diseases

The Burden of Mental Disorders in the Region of the Americas, 2018 9 previous section (except for disaster-related disability in the largest subgroup cause of disability in every country, Haiti, which drives YLDs caused by injuries up to 10% of regardless of income level or subregion. There appears total). The overall variation of NCD disability ranges from to be a subregional gradient in the disability resulting 70% of total YLDs in Haiti to 91% in Mexico. Focusing on from aggregated MNSS (see Figure 8), with South mental illness, the variation ranges between 28% in Haiti American countries occupying the top five positions in to 36% in Brazil, Chile, and Paraguay. Communicable, terms of YLDs, with most countries above the country- maternal, child, and nutritional disorders range from 5% average (33%) and regional aggregate (34%) disability. of YLDs in the United States and Chile to 20% of YLDs in As we will see in the disorder-specific sections, there Venezuela and Haiti (see Figure 7). is a wide variation across countries in terms of which specific mental disorders cause the largest burden. It is Figure 7 shows that disability resulting from MNSS is important for decision-makers to consider the specific remarkably similar (and high) throughout the region. disease profile that affects their country to adequately MNSS constitute indisputably, and by a wide margin, prioritize conditions, allocate investments, and plan

Figure 8: Mental, neurological and substance use disorders and suicide disability tree map (YLDs by country as a percentage of total disability)

Brazil Costa Rica Belize Suriname Panama Bolivia Saint Lucia 36.5% 34.1% 33.4% 32.5% 32.4% 32.3% 32.2%

Chile Argentina Antigua and Barbuda

36.2% 34.0% 34.0% Saint Grenada Guatemala El Salvador Cuba Vincent and the % % % % Paraguay Honduras Bermuda Grenadines 32.1 32.0 32.0 31.6 35.6% 33.5% 33.2% 32.2%

Peru Mexico Dominican Republic 35.5% 33.5% 33.5% Puerto Rico Guyana Venezuela 31.4% 30.6% 28.9% Colombia United States Uruguay Dominica Barbados 35.4% 33.4% 32.9% 31.4% 29.7% Haiti Nicaragua Ecuador Canada Jamaica Virgin Islands U.S. 28.2% 34.7% 33.4% 32.8% 30.8% 29.6% Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar burdens are clustered together in the same region of the tree map.

10 The Burden of Mental Disorders in the Region of the Americas, 2018 Disability resulting from specific disorders service delivery. when properly studied emerges as the single most prevalent mental disorder, affecting 8% of the general population Common mental disorders yearly (21)—is systematically and erroneously conflated with musculoskeletal disorders, leading to inflation of that Common mental disorders generally comprise depressive category despite the absence of a causal link of these and anxiety disorders. It is necessary to point out, syndromes to the musculoskeletal system (15,22). Similarly, however, that a number of other very common mental personality disorders—a group of behavioral and mental and behavioral syndromes are not considered in typical syndromes frequently comprising problematic interpersonal burden of disease calculations and analyses, despite their functioning, affective and cognitive symptoms, impulsivity, significant prevalence, disability, and mortality (15,19). Of self-harm, and somatic complaints—are not considered at note, personality disorders and somatic symptom disorders all in burden of disease calculations despite the fact that are excluded due to the lack of consistent cross-country they are highly prevalent (4 to 15% in community surveys) data, and self-harm and suicide are considered under the (23). Following the method described in detail elsewhere heading of injuries, despite the well-established fact that (15), this study includes self-harm and an estimation for mental disorders and sub-threshold syndromes are largely pain disorders, thus indirectly capturing a fraction of the responsible for intentional self-harm (15,20). The result disability resulting from personality disorders and the is that somatoform disorders with predominant pain—a excess death from depression and other mental illnesses psychiatric disorder formerly known as pain disorder, which due to suicide. Given the high prevalence of these mental

The Burden of Mental Disorders in the Region of the Americas, 2018 11 and behavioral syndromes, they are considered in this general population, to be the fifth-most disabling human section of common mental illness. health state, after acute schizophrenia, untreated neck- level spinal cord lesion, severe multiple sclerosis, and Depressive disorders severe heroin dependence (24). Even mild depressive disorders and dysthymia are considered highly disabling, For the purpose of the current analysis, depressive at the same level of, for example, severe anemia or disorders comprise depressive disorder and dysthymic uncontrolled asthma. The disability resulting from disorder. Depressive disorder can be a highly disabling depressive disorders, both at the individual and at the condition, as reflected by its disability weight in the population level can be considered as a continuum of burden of disease framework. Severe depressive health states from moderately to severely disabling. episodes are considered, based on surveys of the

Figure 9: Depressive disorder disability tree map (YLDs by country as a percentage of total disability)

Paraguay Bermuda Suriname Nicaragua Saint Lucia Argentina Jamaica Bolivia 9.4% 8.1% 7.9% 7.8% 7.8% 7.8% 7.7% 7.7%

Brazil Antigua and Barbuda 9.3% 8.1% Saint Vincent and Puerto Rico Trinidad & Dominica Panama Tobago the Grenadines % % % Chile 7.5 7.5 7.4 Peru 7.7% 7.5% 8.6% 8.1% Grenada 7.6% Costa Rica United States El Virgin Guatemala Ecuador Salvador Islands, 8.0% Honduras 7.4% U.S. 6.8% 8.3% 7.2% 7.6% 7.0% Barbados Colombia Belize Uruguay 8.2% 8.0% 7.4% 7.6% Haiti Canada

Guyana 6.7% 5.9% Dominican Republic Cuba Mexico Venezuela 8.2% 7.9% % 7.3% 7.6 6.7% Latin Central America Non-Latin Caribbean South America Canada & US

12 The Burden of Mental Disorders in the Region of the Americas, 2018 At the regional level, this analysis places depression at of the 14.5 million depression YLDs in the Americas fall the top of disability causes, with 7.8% of total disability, within the 15- to 50-year-old age group (see Figure 10). and a range from 5.9% in Canada to 9.4% in Paraguay. A subregional pattern of increased disability in South America is evident, as indicated by the following: (a) Paraguay, Brazil, Anxiety disorders Peru, Ecuador, and Colombia constituting the top five in the depression disability ranking; and (b) a clear majority This group of disorders comprises many syndromes of South American countries at or above the country- characterized by prominent anxiety, such as generalized average (7.7%) and regional aggregate (7.8%) (see Figure anxiety disorder, panic disorder, social anxiety disorder, 9). Another important aspect of depressive disorders and others. From a disability perspective, they can range is that they affects mainly the young: nearly 10 million from severely disabling to mildly troublesome, and for

Figure 10: Depressive disorder: years lived with disability by age groups (total of YLDs)

15M

14M

13M

12M

11M

10M

7M Total YLDs Total

1M 0M 5-14 years 15-49 years 50-69 years 70+ years All Ages

The Burden of Mental Disorders in the Region of the Americas, 2018 13 our 2015 data analysis we consider them aggregated, disability (3.4%), followed by Mexico (3.6%) and the USA including post-traumatic stress disorder and obsessive- (4.1%) also well below the regional average and aggregate. compulsive disorders.

Anxiety disorder is the second-most disabling mental Self-harm and suicide disorder in most countries of the Americas. A subregional pattern is even more discernible than for depressive Given the well-established relationship of common mental disorders, with Brazil at the top (7.5%); all but one South illnesses (such as depressive and personality disorders) American country showing above country-average (4.7%) with suicide and self-harm, these illnesses are considered and regional aggregate (4.9%) disability; and 8 of the in this section. The burden of disease framework does not top 10 countries in terms of disability corresponding to include personality disorders, a well-established cause of this subregion (see Figure 11). North America falls at the non-lethal self-harm (23,27), and YLDs resulting from self- other end of the spectrum, with Canada showing the least

Figure 11: Anxiety disorders disability tree map (YLDs by country as a percentage of total disability)

Brazil Peru Suriname Bolivia Saint Lucia Grenada Guyana Saint Vincent and the 7.5% 5.3% 4.9% 4.9% 4.8% 4.8% 4.8% Grenadines 4.8%

Ecuador Paraguay 5.2% 6.8% Jamaica Nicaragua Haiti Barbados Honduras Dominican 4.7% 4.4% 4.4% 4.4% 4.3% Republic Chile 5.2% Dominica % 5.5 4.6% Uruguay Virgin Islands U.S. Guatemala Panama El Salvador Argentina 5.2% Cuba 4.1% 4.0% 4.0% 4.0% 5.4% 4.6% Antigua Costa Rica Colombia and Barbuda Trinidad & Tobago 4.1% 5.3% 5.0% 4.6% Venezuela Canada

Bermuda United States 3.6% 3.4% Belize Puerto Rico Mexico 5.3% 4.9% % 4.1% 4.4 3.5% Latin Central America Non-Latin Caribbean South America Canada & US

14 The Burden of Mental Disorders in the Region of the Americas, 2018 harm are not captured in the burden of disease framework. (see Figure 12). The toll that suicide takes in the Americas Therefore, this section will focus on suicide DALYs, which is daunting, and it falls mainly on younger working-age are largely due to years of life lost due to premature death. populations: 60% of the nearly 100,000 suicides occurred between 15 and 50 years of age; 4,129,576 years of life Suicide is the fifth highest cause of DALYs in the Americas, were lost, of which around 75% were lost by this same age with an almost nine-fold range in terms of percentage of group (see Figure 13). total burden, from 0.4% in Antigua and Barbuda to 3.6% in Suriname. There is a remarkable subregional pattern affecting Suriname (3.6%), Guyana (3.5%), and, to a lesser Somatoform disorders/persistent extent, nearby Trinidad and Tobago (2.1%); as well as Uruguay somatoform pain disorder (2.6%), Chile (2.5%), and Argentina (2%) in South America. The United States (2.2%) plus Canada (2.1%) also comprise Somatoform disorders with predominant pain are poorly subregional clusters affected by suicide well in excess of the understood syndromes and thereby frequently ignored country-average (1.5%) and aggregate (1.6%) percentages by clinicians, psychiatrists, and epidemiologists (22,28).

Figure 12: Suicide and self-harm burden tree map (DALYs by country as a percentage of total disability)

Suriname Canada Cuba El Salvador Costa Rica Venezuela Bolivia 3.6% 2.2% 1.9% 1.9% 1.9% 1.7% 1.7%

Trinidad & Tobago

Guyana 2.1% Ecuador Belize Grenada Saint Lucia Brazil 3.5% 1.5% 1.2% 1.1% 1.1% 1.1% United States Paraguay Colombia 2.1% Dominican Bermuda Honduras Haiti 1.2% Republic 1.4% 0.9% 0.9% 0.9% Uruguay Guatemala 1.2% 2.6% Argentina 1.2% 2.0% Mexico Saint Vincent and 1.3% the Grenadines Virgin Islands,U.S. Peru Jamaica Chile Nicaragua 0.8% % % Panama 1.2% 0.7 0.6 2.5% % Puerto Rico Dominica Barbados Antigua and 2.0 1.2% Barbuda 1.2% 0.8% 0.7% 0.4% Latin Central America Non-Latin Caribbean South America Canada & US

The Burden of Mental Disorders in the Region of the Americas, 2018 15 When properly studied, however, they are highly prevalent, traumatic stress disorder populations (29). Routine burden especially in women: the 12-month prevalence of DSM-IV of disease assessments assign 0% of the burden of painful pain disorder has been established by one study as 11% syndromes to mental disorders, an assumption lacking for females and 4% for males, with an overall rate of 8%, minimal face validity. Reattributing a fraction of this burden the largest for any mental disorder (21). Some 56% of pain to MNSS as described elsewhere yields an estimate of disorder patients meet the criteria for another psychiatric 4.7% of total YLDs due to somatic symptom disorder with disorder, most frequently depressive or anxiety disorders. prominent pain (15). The estimated range is between 6.2% The prevalence of painful syndromes in patients diagnosed in Canada and 3.2% in Haiti, and higher-income countries with depressive or anxiety disorders has been found seem to be more affected than lower-income countries. to be greater than 30%, and up to 80% in specific post- These estimates should be considered indicative until

Figure 13: Total years of life lost by age group*

4200K

4000K

3800K

3600K

3400K

3200K

3000K

2800K

2600K

2400K

2200K

2000K

1800K Total years of life lost of life years Total 1600K

1400K 4,129,576 3,126,880 1200K

1000K

800K

600K

400K 804,402 200K 74,718 123,575

0K 5-14 years 15-49 years 50-69 years 70+ years All Ages

*Columns represent total YLLs in the Americas for four separate age groups, and a fifth column for all ages.

16 The Burden of Mental Disorders in the Region of the Americas, 2018 primary data on somatoform disorders disability become The regional variation of schizophrenia disability as available. Of note, the importance of this issue has led a percentage of total disability ranges between 1.1% to the recent creation of a specific section to screen for in Haiti and 2.5% in the United States (see Figure 14). somatic symptom disorders in the WHO World Mental Subregional patterns are less clear, but the USA, Canada, Health Composite International Diagnostic Interview, to and most South American countries are above the be administered in future World Mental Health Surveys, country average (1.6%). Several factors could explain an filling this gap. increasing share of the disability as income level grows, most notably increased premature mortality and/or decreased case-detection capacity in poor settings. Severe mental disorders Research has shown that people with schizophrenia die between 10 and 30 years younger than their peers, Schizophrenia and bipolar disorders are usually referred to with the worst outcomes seen in low-income countries as severe mental disorders. Indeed, they exact some of the (17,31), which would explain the decreasing share of the largest tolls conceivable on human beings: acute psychotic resulting survival with disability. episodes in the context of schizophrenia are considered the most disabling health state in the burden of disease framework (24); manic episodes are highly disabling Bipolar disorders medical emergencies, frequently leading to socioeconomic ruin, injury, or death if untreated; and depressive episodes Bipolar disorders are the cause of significant disability and in the context of bipolar illness can be as severe as those mortality in the Americas. Clinical presentation is highly of depressive disorder, particularly in the context of bipolar variable both across and within cases: some episodes disorder type II. Severe mental illness is particularly lethal constitute mild or moderate fluctuations in mood that are in low-income settings, which tend to also be contexts of compatible with a high functionality and quality of life, while high stigma. The increased lethality is due to the lack of others evolve into severe depressive or manic episodes, effective mental care and to inadequate general medical the former of which can lead to suicide, and the latter, as care for people with severe mental disorders, which lead to mentioned before, to death, disability, or socioeconomic largely preventable excess mortality. The lack of effective, ruin if untreated. So, unlike the uniformly high disability accessible, or even available services, coupled with the resulting from schizophrenia, disability resulting from bipolar catastrophic economic and emotional burden on families, disorders can range from mild dysfunction during residual frequently lead to systematic human rights abuses in states to almost complete impairment during severe manic lieu of treatment, resulting in what has been memorably and depressive episodes. For the purposes of our analysis, labeled a “failure of humanity” (30). Indeed, as detailed in bipolar disorders comprise types I and II, characterized the section devoted to the health system response, lower by manic and hypomanic episodes, respectively. The country income is associated with decreased availability of latter constitutes a milder and shorter behavioral and services, worse services when available, and earlier death psychological activation syndrome than the former. for severe mental illness. A subregional pattern seems to emerge for bipolar disorder disability: every country in continental Central America is Schizophrenia above the country-average and regional aggregate of 1.4% (see Figure 15), while both Canada and the United States In the burden of disease framework, the schizophrenias are below the aggregate (1.3% and 1.2%, respectively). The are considered the most disabling human disorders, range is between 1.1% of total YLDs in the Virgin Islands to particularly during acute episodes. 1.7% in Nicaragua.

The Burden of Mental Disorders in the Region of the Americas, 2018 17 Substance use and eating varying severities that range from the low impairment of mild disorders cannabis use disorder to the almost total disability resulting from severe heroin dependence, and including the moderate Disorders stemming from the use of substances (alcohol, disability resulting from anorexia and bulimia. drugs, or food) are frequently considered together due to their similar clinical pattern, mostly related to their compulsive Disorders due to use of alcohol nature and the direct behavioral dysfunction they entail. This makes them different from smoking, which entails mostly The disability resulting from alcohol use disorders indirect disability through its physical consequences. The ranges from 0.5% in Paraguay to 1.9% in Guatemala current analysis focuses on alcohol use disorder, substance and El Salvador. It presents a subregional pattern with use disorders, and eating disorders. These disorders include the United States, Canada, and most South American

Figure 14: Schizophrenia disability tree map (YLDs by country as a percentage of total disability)

United States Mexico Peru Dominican Nicaragua Trinidad Barbados Republic 2.5% 1.8% 1.7% 1.7% & Tobago 1.6% 1.7% 1.6%

Colombia Chile 1.8% Brazil Suriname Belize Honduras Venezuela 2.1% 1.6% 1.5% 1.5% 1.5% 1.5%

Cuba Argentina 1.7% Ecuador 1.9% 1.6% Dominica El Salvador Jamaica Panama Saint Lucia 1.5% 1.4% 1.4% Uruguay 1.7% 1.9% 1.6% Grenada 1.5% Bolivia Guyana Guatemala Bermuda Costa Rica Puerto Rico 1.4% 1.3% 1.3% 1.7% Virgin Islands U.S. 1.9% 1.6% 1.5% Antigua & Canada Saint Vincent and Barbuda the Grenadines Paraguay 1.8% 1.7% 1.5% 1.5% Haiti 1.1% Latin Central America Non-Latin Caribbean South America Canada & US

18 The Burden of Mental Disorders in the Region of the Americas, 2018 countries well below the country average of 1.2% (only (YLLs), both directly and through excess death due to Chile exceeds it at 1.5%), and at or below the regional cardiomyopathy, liver cancer, and cirrhosis. aggregate (0.9%). Meanwhile, every country in Central America and the Caribbean is above the regional Disorders due to substance use aggregate, and most are above the country average (see (not alcohol) Figure 16). We consider here together cannabis, cocaine, It should be noted that Figure 16 represents years lived amphetamine, and opioid use disorders. The variation with disability (YLDs), but alcohol use disorders also in disability burden resulting from drug use ranges from impose a significant burden in terms of years of life lost 0.5% in Barbados and 0.6% in Haiti and Cuba, to 3.1% in

Figure 15: Bipolar affective disorder disability tree map (YLDs by country as a percentage of total disability)

Nicaragua Guatemala Dominican Argentina Paraguay Venezuela Brazil Antigua Republic and 1.7% 1.5% 1.5% 1.4% 1.4% 1.4% Barbuda 1.5% 1.5%

Peru Colombia 1.5% Bermuda Saint Lucia Saint Vincent Jamaica Canada 2.5% and the 1.4% 1.3% Grenadines 1.3% 1.3%

El Salvador 1.3% Honduras 1.5% Grenada % 1.4% 1.7 Dominica Guyana Puerto Rico Haiti Chile 1.3% 1.3% 1.3% 1.3% Costa Rica Bolivia 1.5% 1.6% 1.4% Trinidad & Tobago Belice Mexico Uruguay 1.3% 1.5% United States Virgin 1.6% 1.4% Islands, 1.2% U.S. Cuba Ecuador Suriname 1.1% Panama 1.3% Barbados 1.6% 1.5% 1.4% 1.2%

Latin Central America Non-Latin Caribbean South America Canada & US

The Burden of Mental Disorders in the Region of the Americas, 2018 19 the United States (see Figure 17). This six-fold variation Eating disorders reflects the raging epidemic of opioid use disorders affecting the United States and Canada (2.5%); in both Anorexia and bulimia together account for a comparably of which, the specific burden of opioid use disorders much smaller fraction of total burden; between 0.07% constitutes around 70% of all drug use disability. in Haiti and 0.42% in the United States. Only the United States and Canada are above the regional aggregate As is the case with alcohol, other substance use percentage of 0.3%, indicating that the burden of eating disorders cause a significant number of years of life lost disorders falls mostly on well-off countries. across the region, but most notably in the United States and Canada, where they produced 1.73% and 0.92% of total years of life lost, respectively.

Figure 16: Disorders due to use of alcohol disability tree map (YLDs by country as a percentage of total disability)

Guatemala Nicaragua Belize Haiti Cuba Suriname Puerto Rico 1.9% 1.6% 1.5% 1.4% 1.4% 1.3% 1.3%

Grenada El Salvador 1.6% 1.9% Costa Rica Mexico Honduras Colombia Panama % % % % % Dominica 1.3 1.1 1.1 1.0 1.0 1.6% Saint Vincent and the Trinidad & Tobago Grenadines 1.2% Barbados Venezuela Canada 1.9% Chile 1.0% 0.9% 0.9% 1.5% Dominican Republic Virgin Islands, U.S. 1.2% Jamaica 1.7% Saint Lucia 1.0% Bolivia Peru 1.5% Argentina 0.9% 0.8% 1.2% United States 0.9% Antigua and Barbuda Uruguay Paraguay Guyana Bermuda 1.7% 1.5% Ecuador 0.6% 0.5% 1.1% 0.9% Brazil 0.6% Latin Central America Non-Latin Caribbean South America Canada & US

20 The Burden of Mental Disorders in the Region of the Americas, 2018 Disorders with onset usually conduct disorders (0.7%), intellectual disability (0.2%), occurring in childhood and and attention-deficit and hyperactivity disorder (0.1%). They show a clear subregional pattern, with all continental adolescence Central American countries and all South American countries above the regional aggregate percentage. Collectively, disorders that affect mainly children and Conversely, most of the English-speaking Caribbean adolescents account for 2.2% of total YLDs in America. islands, the United States, and Canada (1.8% in both) show They include, in order of importance, autism (1.2%), the lowest burden (see Figure 18).

Figure 17: Disorders due to substance use (not alcohol) disability tree map (YLDs by country as a percentage of total disability)

United States Peru Suriname Ecuador Uruguay Costa Rica Panama 3.1% 1.3% 1.0% 1.0% 1.0% 0.9% 0.9%

Guatemala 1.2% Honduras Saint Vincent Belize Colombia Antigua and the and Barbuda 0.9% Grenadines 0.9% 0.9% 0.9% Canada 0.9% 2.5% Bolivia 1.2% Guyana Nicaragua Saint Trinidad Venezuela Lucia & Tobago Chile 0.9% 0.8% 0.8% 0.8% 0.8% Puerto Rico 1.2% 1.6% Virgin Islands, U.S. 0.9% Mexico Jamaica Paraguay Cuba

Argentina 1.1% Dominica 0.8% 0.7% 0.6% 1.3% 0.8% Dominican Republic Grenada 0.7% Haiti Barbados Bermuda Brazil 1.1% El Salvador 0.6% 0.5% 1.3% 0.8% 0.7% Latin Central America Non-Latin Caribbean South America Canada & US

The Burden of Mental Disorders in the Region of the Americas, 2018 21 Neurological disorders GDP with a higher percentage of total disability attributable to the dementias. This is an expression of the demographic This category includes the disability resulting from change in age structure, where increased survival, and neurocognitive disorders—such as Alzheimer’s disease, disability resulting from the disorders of older adults, epilepsy, migraine, and tension-type headache, all of accompanies economic development (see Figure 19). which have prominent mental and behavioral syndromes. Epilepsy Neurocognitive disorders Epilepsy is responsible for 0.8% of total disability in Alzheimer’s and other dementias account for 1.2% of total the region, ranging between 0.2% in Canada and 1.6% disability, ranging from 0.4% in Haiti to 1.9% in Canada. in Honduras. Subregionally, epilepsy produces a lower They reflect a highly significant trend, correlating higher percentage of disability in Canada and the United

Figure 18: Disorders with onset usually occurring in childhood and adolescence disability tree map

Honduras Ecuador Dominican Argentina Costa Rica Guyana Venezuela Republic 2.6% 2.5% 2.5% 2.5% 3.3% 2.8% 2.6%

Guatemala Peru 3.2% 2.8% Haiti Grenada Bermuda Antigua Saint and Vincent % 2.3% 2.3% Barbuda and the 2.4 Grenadines Nicaragua Paraguay 2.3% 2.3% 3.2% 2.8% Chile 2.4% Jamaica United Canada Cuba Mexico El Salvador States Suriname 2.2% 1.8% 1.8% 3.1% 2.7% 1.8% 2.3% Saint Lucia

Bolivia Panama 2.1% Uruguay 2.9% 2.7% Dominica Puerto Rico Virgin 2.3% Islands. 2.1% 1.8% U.S. Belize Colombia Brazil 1.7% Trinidad & Tobago Barbados 2.8% 2.7% 2.3% 1.9% 1.8%

Latin Central America Non-Latin Caribbean South America Canada & US

22 The Burden of Mental Disorders in the Region of the Americas, 2018 Figure 19: Dementia disability tree map

Canada Barbados Brazil Dominican Bermuda Saint Lucia Colombia 1.9% 1.3% 1.0% Republic 0.9% 0.9% 0.9% 0.9%

Costa Rica United States 1.2% Dominica Paraguay Jamaica Bolivia Grenada 1.6% 0.9% 0.8% 0.8% 0.8% 0.8% Uruguay 1.1% Nicaragua Puerto Rico 0.8% Chile Venezuela Saint % Vincent 1.4 El Salvador 0.8% 0.7% and the Peru 1.1% Grenadines 0.8% Trinidad & Tobago 0.7% Cuba 0.8% Suriname Guatemala Panama 1.3% Argentina 0.7% 0.7% 1.1% 0.8% Antigua and Barbuda 0.7% Virgin Islands, U.S. Guyana Mexico Ecuador Belize Honduras 1.3% 1.0% 0.8% 0.4% 0.4% 0.7% Haiti 0.4% Latin Central America Non-Latin Caribbean South America Canada & US

Tree map dimensions: the color indicates the subregion and the size of each rectangle reflects the magnitude of the burden. Countries with similar burden are clustered together in the same region of the tree map.

States, and a larger proportion in Honduras, Guatemala, does not appear to be a subregional pattern for either and Mexico. In fact, most countries in Central America, condition. However, the significant burden of headache- South America, and the Caribbean are above the regional related disability and its potential implications for health aggregate percentage (see Figure 20). systems–namely, the need for widespread training of primary care workers in their detection and management— Migraine and tension-type headaches have only recently come to the fore.

Migraines account for 4.4% of the regional disability burden, ranging from 3.6% in the United States (3.6%) to 5.4% in Peru. Tension-type headaches produce a comparatively lower regional burden (0.3%), and there

The Burden of Mental Disorders in the Region of the Americas, 2018 23 Figure 20: Epilepsy disability tree map

Honduras Haiti Venezuela Suriname El Salvador Saint Bolivia Vincent 1.6% 1.2% 1.1% 1.1% 1.1% and the 1.0% Grenadines 1.0% Dominica Guatemala 1.6% 1.2% Saint Lucia Trinidad & Jamaica Paraguay 1.0% Tobago 0.9% 0.9% Panama 0.9% Mexico 1.2% 1.4% Antigua and Barbuda 1.0% Uruguay Dominican Barbados Brazil Ecuador Republic Chile 0.8% 1.6% 0.7% 1.2% Belize 0.7% 1.3% 1.0% Peru Nicaragua Grenada Bermuda Puerto Rico United 1.3% 1.2% States 1.0% 1.6% 0.6% % Cuba 0.5 Costa Rica Colombia Guyana Virgin Islands, 0.6% % U.S. 1.3% 1.2 0.9% Argentina Canada 0.6% 0.5% 0.2%

Latin Central America Non-Latin Caribbean South America Canada & US

24 The Burden of Mental Disorders in the Region of the Americas, 2018 Health system response in the Americas: Government funding for mental health services

This section will focus on how our societies respond was supplemented with additional published data when to the challenge presented by the MNSS. In so doing, missing, or when more recent WHO-AIMS country-level this study will analyze how investment in mental health data were available (range: 2009-2015). For countries services and allocation of spending vary as a function of or territories with unavailable data for mental health national income. As a result, simple intuitive metrics are spending or for fraction spent on mental hospitals, we presented that allow for comparison of the gap between imputed the median regional value. We excluded countries burden and spending across countries. missing both data points, as well as territories without burden of disease data. We also obtained 2015 real The present analysis is based on a set of estimates of per-capita GDP from the International Monetary Fund’s health spending and allocation obtained by collating the World Economic Outlook Database. For the British Virgin latest available data reported to PAHO by governments Islands we imputed the subregional median for the Non- of the Americas and published in the WHO Assessment Latin Caribbean territories. A limitation to the following Instrument for Mental Health Systems (WHO-AIMS). This analysis emerges from the fact that these data are self-

The Burden of Mental Disorders in the Region of the Americas, 2018 25 reported by ministries of health to WHO, and its quality health care (32,33). In practical terms, this means that is variable due to lack of unified reporting criteria about physical and mental health services should be provided which types of expenditures are included or excluded. in an integrated manner, and that the percentage of For example, potentially significant resources allocated spending allocated to mental health services should to dementia care or suicide prevention, or services be proportionate to the percentage of its attributable delivered through the non-health sectors are probably not burden. There are several challenges to operationalizing captured in these estimates. However, even considering these concepts: (a) as noted earlier, the DALY burden for these limitations, it is unlikely that inconsistencies in the mental disorders is usually underestimated due to lack of inclusion of dementia, suicide prevention, or non-health registration of deaths due to most mental illnesses. YLDs sector expenditures would decrease the imbalance found would provide a less biased comparator for disability in low-income countries. In fact, it is actually more likely across diseases, because disability is adequately that these expenditures would be much higher in high- registered for all disorders through prevalence estimates. income countries, thus increasing the strength of the However, since YLDs do not include mortality, they inverse correlation shown here. Therefore, the following would not be appropriate as the only measure of overall findings about the imbalance between the burden and the burden. Also, (b) reporting mental health expenditures spending on mental health services can be considered as a specific percentage of total government health conservative. spending is inconsistent across countries due to the lack of a unified reporting strategy (e.g. which types of services are included or excluded, how to estimate Mental health spending as a services delivered through other sectors, etc.). Moreover, percentage of government it does not account for private spending, which in many countries is the main source of mental health funding. health spending Despite these caveats, a simple measure is provided of mental health spending gap resulting from dividing the Median spending in mental health services stands percentage of total DALYs attributable to MNSS by the globally at 2.8% of total government health spending, percentage of the government health budget allocated to despite the fact that mental disorders account for 12% of mental health services. A ratio of 1 would entail equality total DALYs and 35% of total YLDs. Low-income countries between the proportions of disease burden and spending, spend around 0.5% of their health budget in mental implying the assumption of equivalent cost-effectiveness health services, and high-income countries, 5.1% (15). of interventions across health sectors, which would not In the Americas, spending ranges from 0.2% in Bolivia be based on current evidence. to 8.6% reported by Suriname. There is a significant direct linear correlation between national income and Figure 22 shows all countries ordered by the ratio of mental Government spending in mental health as a proportion illness burden to expenditure on mental health. A wide of the total health budget (see Figure 21). regional variation is evident, ranging from a burden that is 1.8 to 72 times the reported spending. The median for countries WHO recommends that health spending allocation should of the Americas is 6.1, indicating that the proportion of be in proportion to the health burden, and that there burden attributable to mental disorders is 6 times the should be parity between physical and mental aspects of proportion of health funds allocated to mental health.

26 The Burden of Mental Disorders in the Region of the Americas, 2018 Mental health spending to neuropsychiatric hospitals can be considered a proxy allocation for how well allocated mental health spending is, since asylums lack any evidence of effectiveness, are notoriously The previous analysis, however, does not take into account inefficient, and can in fact lead to iatrogenic practices. allocation of spending within the mental health subsystem. Despite some outliers, a linear trend model correlating the International guidelines and evidence indicate that services natural logarithm of the percentage of the mental health for mental disorders should aim at caring for people in the budget allocated to neuropsychiatric hospitals and 2015 community, providing integrated services for mental illness in GDP is highly significant (see Figure 23). primary care or general hospitals, and community treatment plus social support for severely affected individuals (33). The figure suggests that higher income countries not The fraction of mental health spending that is not allocated only spend a larger proportion of their health budget on

Figure 21: Mental health spending vs. per-capita GDP (PPP)*

2.2 Canada and US Suriname 2.0 Latin Central America United States Non-Latin Caribbean Barbados Canada 1.8 Uruguay South America Jamaica 1.6 Saint Vincent and the Grenadines 1.4 Saint Lucia Antigua and Barbuda 1.2 Dominica British Virgin Islands Trinidad & Tobago Argentina Peru 1.0 Panama 0.8 Turks and Caicos Brazil Chile 0.6 Haiti Costa Rica Mexico Belize 0.4 Honduras Montserrat 0.2 Guyana Ecuador -0.0 El Salvador Saint Kitts and Nevis Paraguay -0.2 -0.4 Nicaragua -0.6 % allocated to Guatemala mental health -0.8 0.200 -1.0 Dominican Republic 2.000 4.000 -1.2 6.000 -1.4 8.600 -1.6 Bolivia -1.8

In (% of government health spending allocated to mental health services) to health spending allocated In (% of government 7.4 7.6 7.8 8.0 8.2 8.4 8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0 10.2 10.4 10.6 10.8 11.0 In (GDP 2015)

*Linear model: ln (% of health expenditures spent on MNSS) = 0.68*ln (GDP) + -5.6. R2:0.26. p=0.0036. Confidence bands show upper and lower 95% confidence lines. MNSS: Mental, neurological, substance use disorders and self-harm GDP (PPP): gross domestic product, purchasing-power parity adjusted

The Burden of Mental Disorders in the Region of the Americas, 2018 27 mental health services, but also potentially allocate that be managed in the community over the spending not increasing proportion better, to mental health services that absorbed by neuropsychiatric hospitals, a very different are evidence-based and follow international guidelines, ordering can be obtained (compare Figures 22 and providing integrated treatment in general health services 24).1 It is clear that in terms of percentage of burden and community support. This community-based approach over percentage of spending efficiently allocated, the is respectful of the social and human rights of patients, as imbalance varies by two orders of magnitude: from the opposed to asylum-based segregationist approaches that burden being three times the spending in the USA and foster isolation and potentially human rights violations. Canada to 435 times the spending in Haiti. The regional median indicates an imbalance between mental health In order to visualize the magnitude of the imbalance in burden and spending of 31.5 to 1. What this metric spending, and considering the mental burden that should indicates is that there is a gap in spending associated

Figure 22: Ratio of % of total DALYs attributable to MNSS to % of health spending allocated to mental health, ordered from smallest to largest

72.1

37.1

28.5 24.1

16.9 15.4 m=6.1 13.9 10.3 9.1 9.6 10.2 7.2 8.0 8.2 Ratio of mental health burden to expenditures of mental health burden to Ratio 5.6 5.7 6.4 3.8 3.9 4.2 4.3 4.4 4.4 1.8 1.9 2.3 2.4 2.5 2.7 3.2

Haiti Peru Brazil Chile Belize Bolivia Canada Mexico Guyana JamaicaUruguay Panama Ecuador Barbados Dominica Paraguay Suriname Argentina Honduras Nicaragua Saint Lucia Costa Rica El Salvador Guatemala United States

Trinidad & Tobago Dominican Republic British VirginAntigua Islands and Barbuda Saint Vincent and the...

MNSS: Mental, neurological, substance use disorders and self-harm m indicates the regional median value

1 This study subtracted from the numerator the percentage of burden attributable to the most severe health state associated with schizophrenia (69%), assuming that neuropsychiatric hospitals would be adequately suited to treat this fraction of the most severely affected. From the denominator, this study subtracted the fraction of spending allocated to neuropsychiatric hospitals.

28 The Burden of Mental Disorders in the Region of the Americas, 2018 with country-level income, disproportionately affecting undertreatment, which a recent study estimated to be lower-income countries. 5 to 1 for depressive disorder in high-income countries. As such, only 22.4% received minimally adequate This gap likely results in (a) an increasing treatment treatment in high-income countries, and specifically gap for poorer countries and (b) increased private 26% in the United States (34). In low- or lower-middle spending in mental health services, particularly out-of- income countries, the ratio was estimated at 27 to 1, pocket expenses. For example, the 3 to 1 imbalance with only 4.7% of people in need receiving minimally documented in Canada and the United States results in adequate services. Specifically, it was found that in Peru,

Figure 23: MNSS spending allocated to mental hospitals vs. GDP (PPP)1

Canada and US 5.8 Latin Central America Non-Latin Caribbean 5.6 South America 5.4 5.2 5.0

4.8 Saint Vincent and the Grenadines Nicaragua Saint Lucia Trinidad & Tobago 4.6 El Salvador Peru Haiti Guatemala Paraguay Barbados Suriname Saint Kitts and Nevis 4.4 Honduras Jamaica Bolivia Dominica Mexico Antigua and Barbuda 4.2 British Virgin Islands Uruguay Costa Rica Argentina 4.0 Guyana Ecuador Dominican Republic 3.8 Brazil Panama 3.6

3.4 % spent on mental hospitals Belize 3.2 10.00 3.0 20.00 40.00 2.8 60.00 80.00 Chile 2.6 100.00 United States

In (% of mental health spending allocated to mental health services)* to In (% of mental health spending allocated 2.4 Canada 2.2 7.3 7.5 7.7 7.9 8.1 8.3 8.5 8.7 8.9 9.1 9.3 9.5 9.7 9.9 10.1 10.3 10.5 10.7 10.9 11.1 In (GDP 2015)

*Linear model: Ln (% MNSS expenditures spent on mental hospitals) = -050*ln(GDP) + 8.9. R2=0.32. p=0.0012. Confidence bands show upper and lower 95% confidence lines. MNSS: Mental, neurological, substance use disorders and self-harm GDP (PPP): gross domestic product, purchasing-power parity adjusted

1 Figures 21 and 23 raise the possibility that Haiti, Canada, and the United States may be outliers and influence our results. Hence, we re-ran the analyses excluding Haiti, Canada, and the US for both models. The results and their significance hold for the model correlating the fraction of overall health expenditures spent on mental health with GDP (with a p value <0.05) but lose significance for the model correlating the fraction spent on mental hospitals with GDP.

The Burden of Mental Disorders in the Region of the Americas, 2018 29 one person received minimally adequate treatment for further study, for example, about whether the imbalance every 100 persons with a valid diagnosis of depressive found is partly closed by private spending, leading to disorder. These numbers are consistent with the findings the 100 to 0.9 undertreatment found by Thornicroft et presented herein: (a) the United States and Canada show al., which in low-income countries would mean mostly the lowest imbalance and (b) Peru has one of the largest out-of-pocket spending, piling potentially catastrophic gaps in the continent, with a 313-fold imbalance in burden economic burden upon the disease burden (34). relative to government spending. These findings merit

Figure 24: Imbalance in spending: ratio of MNSS burden to efficiently allocated spending *

435

352 312 279 261 244

185 188

123 m=31.5 103 73 63 72 39 Ratio of MNSS burden to efficiency of MNSS burden to Ratio expenditures allocated 26 30 33 14 16 20 21 22 3 3 8 10 11 11 11 11

Peru Haiti Chile Brazil Belize Bolivia Canada Guyana Mexico Uruguay Panama Jamaica Ecuador Dominica Paraguay Barbados Suriname Argentina Honduras Nicaragua Costa Rica Saint Lucia El Salvador Guatemala United States

Trinidad & Tobago Dominican Republic British VirginAntigua Islands and Barbuda Saint Vincent and the...

MNSS: Mental, neurological, substance use disorders and self-harm m indicates the regional median value

* This ratio excludes from the nominator the percent of burden attributable to the most severe form of schizophrenia, and from the denominator the percent allocated to neuropsychiatric hospitals: (mental disorders as % of total DALYs–63% of schizophrenia DALYs)/(% health budget–% spent on neuropsychiatric hospitals). The GBD model estimates that 63% of prevalent cases correspond to acute schizophrenia, which carries a disability weight of 0.778. Meanwhile, 37% of prevalent cases correspond to residual schizophrenia, carrying a disability weight of 0.588 (disability weights range from 0, perfect health, to 1, equivalent to death). As YLLs for schizophrenia are negligible and YLDs result from multiplying prevalent cases by disability weight, it was estimated that 69% of the disease burden of schizophrenia is attributable to the acute state.

30 The Burden of Mental Disorders in the Region of the Americas, 2018 Conclusion

MNSS is a group of diseases and conditions that constitute makers with a nuanced picture of mental disorders in most a major cause of disability and mortality, and give rise countries or territories of the Region. South America has to a third of total YLDs and a fifth of total DALYs in the in general higher proportions of disability due to common Americas. Of the mental disorders, depressive disorders mental illness; suicide imposes a disproportionately high are the largest cause of disability alone, and combined burden on three subregional clusters: Suriname, Guyana, with mortality, accounting for 3.4% of total DALYs and and Trinidad and Tobago; Uruguay, Chile, and Argentina; 7.8% of total YLDs. The second largest subset comprises and Canada and the USA. Depressive disorders take their anxiety disorders, with 2.1% and 4.9%, respectively, of total largest toll on young working-age populations. Continental DALYs and YLDs. Self-harm and somatoform disorders Central America has a larger proportion of disability with prominent pain should also be considered common due to bipolar and childhood onset disorders than other mental disorders, accountable respectively for 1.6% of subregions, as well as due to epilepsy; and the USA and DALYs and 4.7% of YLDs. Severe mental illness leads to Canada suffer a high disability toll from schizophrenia increased mortality, particularly in low-income settings, and dementia, as well as devastating rates of opioid-use with high-income countries thus coping with an increased disorder disability and premature death. share of the disability burden due to schizophrenia. Several subregional patterns emerge in the distribution of specific The health system’s response to the challenge of mental mental disorders, and this report provides decision- illness also shows regional variations, notably a correlation

The Burden of Mental Disorders in the Region of the Americas, 2018 31 with national income. Higher-income countries spend DALYs in the Americas; furthermore, mental health a larger share of their health budgets on mental health is increasingly acknowledged as a global health and services, and appear to allocate their spending more economic development priority. Indeed, the United efficiently, away from neuropsychiatric hospitals, towards Nation’s Sustainable Development Goals explicitly refer integration of mental health into primary care and to universal health coverage inclusive of mental health community resources. Conversely, lower-income settings and well-being as a global commitment. It is imperative seem to compound their lack of resources by allocating that Governments—especially of low- and middle- them to specialized neuropsychiatric hospitals instead of income countries (LAMICS)—reconsider how their health funding community and primary mental health services, a budgets are allocated. Instead of yielding to the inertia of strategy that would target not only the increasing disability minimal—usually reactive—adjustments to last year’s line- resulting from depression and common mental illness, item budgets, they can take bold steps to purposefully but also the amenable mortality resulting from severe allocate funds following a rational assessment of needs, mental illness, largely due to treatable causes that remain priorities, available resources, and existing evidence. uncared for due to stigma, lack of community support, and Despite the obvious constraints that health and mental insufficiently integrated health services. The imbalance health budgets have in LAMICS, there is significant room between the burden and the effectively allocated mental to make meaningful improvements. In fact, it is precisely health services is appalling, ranging from 3 times in the because of these constraints that effective and cost- United States and Canada to 435 times in Haiti, with a effective use of resources is of paramount importance. regional median of 32. This government spending gap, Rather than allocating the lion’s share to specialized which disproportionally affects lower-income countries, hospitals, countries should prioritize funding community can be expected to result in (a) undertreatment and and primary mental health services, following a balanced increased amenable disability and mortality; and (b) care strategy that would target the multiple sources of increased out-of-pocket spending resulting in potentially disease burden resulting from mental disorders: mood catastrophic health spending, and decreased productivity disorders and suicide; substance use disorders and death both at the individual and national level. by overdose or alcohol-related accidents and illnesses; and, finally, the increased mortality resulting from In summary, MNSS is a group of diseases and conditions severe mental illness due to treatable causes that are that are a major cause of disability and mortality, and ineffectively cared for due to stigma, lack of community give rise to a third of total YLDs and a fifth of total support, and poorly integrated health services.

32 The Burden of Mental Disorders in the Region of the Americas, 2018 References

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34 The Burden of Mental Disorders in the Region of the Americas, 2018 Annex 1 Non-Latin Caribbean Subregion Countries and Population

Country Antigua and Barbuda 91,861 Barbados 283,841 Belize 358,715 Bermuda 66,868 Dominica 71,672 Grenada 106,968 Guyana 770,068 Jamaica 2,823,613 Saint Lucia 185,108 Saint Vincent and the Grenadines 109,755 Suriname 542,588 Virgin Islands, U.S. 106,626

The Burden of Mental Disorders in the Region of the Americas, 2018 35