Global Mental Health. Improving Care for Depression J ü rgen Un ü tzer, MD, MPH, MA April 1, 2011. Jürgen Unützer, MD, MPH, MA Professor, Psychiatry & Behavioral Sciences Adjunct Professor, Health Services Director, AIMS Center. Grant funding NIH (NIMH) AHRQ John A. Hartford Foundation
Improving Care for Depression
Jürgen Unützer, MD, MPH, MA
April 1, 2011
updated February 2011
Building on 25 years of Research and Practice in Integrated Mental Health Care
Chronic Physical Pain
Mental Health / Substance Abuse
Smoking, Obesity, Physical Inactivity
10% in primary care, more common inpatients with chronic medical illnesses
PCP supported by Behavioral Health
Caseload-focused psychiatric consultation
50 % or greater improvement in depression at 12 months
Ethnic Minority Populations
50 % or greater improvement in depression at 12 months
Areán et al. Medical Care, 2005
Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (31.1%)
Neuropsychiatric Disorders account for 1.7 % of deaths.
in disability-adjusted life years (DALYs)
Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (42.8%)
Neuropsychiatric Disorders account for 12.3 % of DALYs.
Fig 3: UN, The Population Prospects, 1998 up-date
Change in rank order of DALYs for the 15 leading causes
1999 Disease or Injury
2020Disease or Injury
1. Acute lower respiratory infections
3. Perinatal conditions
4. Diarrhoeal diseases
5. Unipolar major depression
6. Ischaemic heart disease
7. Cerebrovascular disease
9. Road traffic injuries
10. Chronic obstructive pulmonary disease
11. Congenital anomalies
1. Ischaemic heart disease
2. Unipolar major depression
3. Road traffic injuries
4. Cerebrovascular disease
5. Chronic obstructive pulmonary disease
6. Lower respiratory infections
9. Diarrhoeal diseases
11. Perinatal conditions
13. Congenital anomalies
14. Self-inflicted injuries
15. Trachea, bronchus and lung cancers
DALY = Disability-adjusted life year
Source: WHO, Evidence, Information and Policy, 2000
“An estimated 400 million people alive today suffer from mental or neurological disorders or from psychosocial problems related to alcohol and drug abuse.
Many of them suffer silently and alone. Beyond the suffering and beyond the absence of care lie the frontiers of stigma, shame, exclusion and, more often than we care to know, death.
Our advocacy effort will concentrate on reducing stigma associated with mental ill health and neurological disorders and on raising awareness about the many effective, affordable treatments that are available but underused, both in developing and industrialized countries.”
Dr Gro Harlem Brundtland, Director General WHO Geneva, 12 February 2001
DARE TO CARE
Mental Health:Stop exclusion – Dare to care
Охрана психического здоровья:откажитесь от изоляции - окажите помощь
Salud mental:Sí a la atención, no a la exclusión
To raise awareness among youth by addressing issues of stigma and mental health;
Three categories: 6-9 years (drawing); 10-14 years (essay, 250 words); 15-18 years (essay, 500 words);
Public and private schools worldwide;
Winners (1 per category) announced on 7 April (countries/regions); 3 global winners honoured at the WHO World Health Assembly in May, 2001.
I share a desk with a classmate who walks alone on the playground. Overcome by strong feelings of inferiority, he confines himself to a restricted personal space. He is unwilling to interact with others, and others are unwilling to interact with him. Mental illness has caused him to lose all his friends.
His strong feelings of inferiority are due to difficulty in adjusting to a new environment and to the academic pressures. He often goes off by himself and is hostile to the world around him. For example, if the teacher tells us about an accident that resulted in a loss of lives, he would say," "Great! Weneed to reduce the population!" He often stays awake all night for no apparent reason and then tells others that "I've been working hard (at studying) again!". Innumerable strange incidents like these make it difficult to tolerate his behavior. I always try to avoid him and wish there were some way I wuld not have to share a desk with him.
While returning home one day, I saw him squatting alone by some flowery shrubs trying to help an injured butterfly. I was dumbfounded and amazed to find that he was so compassionate! Wasn't he hostile to the whole world? I couldn't help but run over and help him with the butterfly. He glanced gratefully at me and said "Thank you!" At that moment, I felt his trust and for the first time experienced a mutual affinity towards him.
I have the distinct feeling that my desk mate is like the injured butterfly. He needs others to rescue him, to help his spirit fly!
Written by Tang Shu-wei, 14 yr old girl, Guandong Province, China
Mental health is relevant to all of health.
Mental disorders are real, diagnosable, common and universal. If left untreated, they can produce suffering and severe disability in individuals, and major social and economic losses.
Mental disorders are treatable. Prevention and treatment are possible and feasible, but currently most sufferers are unreached.
“The voice of the voiceless”
What are they?
depressedmood, loss of interest and pleasure; symptom severity and duration differentiate them from normal mood changes;
bipolar disorders: depression alternates with mania (exaggerated elation or irritability)
How many suffer?
3 – 10 % of adults
What can be done?
psychosocial interventions (e.g behavioral activation, cognitive-behavior therapy, problem solving treatment, interpersonal therapy).
In Europe, suicide is the 2nd cause of death in persons 15-34 after traffic accidents.
1:WHO (2001), 2:INCLEN - WorldSAFE (2001), 3:Hakimi M et al (2001).
Depression can be reliably diagnosed in primary care. Antidepressant medications and brief, structured forms of psychotherapy are effective for 60-80 % of those affected and can be delivered in primary care.
However,fewer than 25 % of those affected (in some countries fewer than 10 %) receive such treatments. Barriers to effective care include the lack of resources and lack of trained providers.
WHO: Sartorius et al, 1995.
Guide will open
the door to more opportunities
for the management of
disorders that contribute to
suffering among individuals
and their families worldwide”
said Thomas Insel, Director, National Institute
of Mental Health, USA.
What can we learn from effective treatment programs in developed and developing countries?
What are the best opportunities and ‘platforms’ to provide treatment?
What can we do here at UW to help advance effective treatment for common mental disorders worldwide?