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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

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global mental health

Global Mental Health

Improving Care for Depression

Jürgen Unützer, MD, MPH, MA

April 1, 2011

Jürgen Unützer, MD, MPH, MAProfessor, Psychiatry & Behavioral SciencesAdjunct Professor, Health ServicesDirector, AIMS Center
  • Grant funding
    • NIH (NIMH)
    • AHRQ
    • John A. Hartford Foundation
    • American Federation for Aging Research (AFAR)
    • Alaska Mental Health Trust Authority
    • George Foundation
    • California HealthCare Foundation
    • Robert Wood Johnson Foundation
    • Hogg Foundation for Mental Health
  • Contracts
    • Community Health Plan of Washington
    • Public Health of Seattle & King County
  • Consultant
    • AARP Services Incorporated (ASI)
    • National Council of Community Behavioral Health Care (NCCBH)
  • Advisor
    • Carter Center Mental Health Program
    • Institute for Clinical Systems Improvement (ICSI)
    • World Health Organization (WHO)

updated February 2011

university of washington
University of Washington

Building on 25 years of Research and Practice in Integrated Mental Health Care

mental disorders are rarely the only health problem
Mental Disorders are Rarelythe Only Health Problem



Chronic Physical Pain





Mental Health / Substance Abuse

Smoking, Obesity, Physical Inactivity


Heart Disease




improving care for depression
Improving Care for Depression


10% in primary care, more common inpatients with chronic medical illnesses

  • Disabling
    • #2 cause of disability (WHO)
  • Expensive
    • 50-100% higher health care costs
    • (ED, inpatient, outpatient, pharmacy)
  • Deadly
    • Over 30,000 suicides / year
impact team care model
IMPACT Team Care Model



PCP supported by Behavioral Health

Care Manager


Active Patient

Practice Support


Caseload-focused psychiatric consultation


impact doubles the effectiveness of depression care
IMPACT Doubles the Effectiveness of Depression Care

50 % or greater improvement in depression at 12 months


Participating Organizations


IMPACT Care Benefits

Ethnic Minority Populations

50 % or greater improvement in depression at 12 months

Areán et al. Medical Care, 2005

global mental health1
Global Mental Health
  • Refugee / Migrant Health
  • Mental Health (WHO)
    • Senior Advisor, Depression Initiative & World Health Report (2000-2001)
    • Member; mhGAP Guideline Development Group (2009-2010)
  • Consultant on Initiatives to Improve Depression Care in
    • Africa and Latin America
who definition of health
WHO Definition of Health
  • Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1948).

Death, by broad cause group

in 1999


conditions (59.8%)

Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (31.1%)

Injuries (9.1%)

Neuropsychiatric Disorders account for 1.7 % of deaths.

global burden of disease
Global Burden of Disease
  • Harvard School of Public Health , World Health Organization, World Bank – 1993
  • A ‘health gap’ measure: incorporates losses of ‘healthy life’ due to premature death and disability.
  • 1 DALY = 1 year of ‘healthy life lost due to death or disability.
  • References
    • World Bank (1993): World Development Report. NY, Oxford University Press.
    • Murray CJL, Lopez A (eds)( 1996): The Global Burden of Disease. Harvard School of Public Health.
    • Murray CJL, Lopez A (2000): Progress and directions in refining the global burden of disease approach. Health Economics 9: 69-82.

Global burden of disease

in disability-adjusted life years (DALYs)

in 1999


conditions (43.2%)

Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (42.8%)

Injuries (13.9%)

Neuropsychiatric Disorders account for 12.3 % of DALYs.

increasing life expectancy at birth focus on noncommunicable diseases
Increasing Life Expectancy at Birth: focus on noncommunicable diseases

Fig 3: UN, The Population Prospects, 1998 up-date


Increasing Burden of Noncommunicable Diseases and Injuries

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

8. Malaria

9. Road traffic injuries

10. Chronic obstructive pulmonary disease

11. Congenital anomalies

12. Tuberculosis

13. Falls

14. Measles

15. Anaemias

1. Ischaemic heart disease

2. Unipolar major depression

3. Road traffic injuries

4. Cerebrovascular disease

5. Chronic obstructive pulmonary disease

6. Lower respiratory infections

7. Tuberculosis

8. War

9. Diarrhoeal diseases

10. HIV

11. Perinatal conditions

12. Violence

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





Santé mentale:Non à l’exclusion, oui aux soins

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


Global School Contest

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

Released October 4, 2001

World Health Report 2001

Messages (1-3)

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.


World Health Report 2001

  • Recommendations
  • Provide treatment in primary care
  • Make psychotropic medications available
  • Give care in the community
  • Educate the public
  • Involve communities, families, and consumers
  • Establish national policies, programs, and legislation
  • Develop Human resources
  • Link with other sectors
  • Monitor community mental health
  • Support more research.

Gregoire Ahongbonon, Ivory Coast

“The voice of the voiceless”


Depressive disorders

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?

antidepressant medications;

psychosocial interventions (e.g behavioral activation, cognitive-behavior therapy, problem solving treatment, interpersonal therapy).

icd 10 depression
ICD-10 Depression
  • At least two of three core symptoms
    • Low sad or mood
    • Loss of interest or pleasure in daily activities
    • Lack of energy or increased fatiguability
  • And at least two of the remaining symptoms
    • Disturbed sleep
    • Disturbed appetite
    • Restlessness or slowing of movements or speech
    • Feelings of guilt or unworthiness
    • Reduced self esteem or self confidence
    • Poor concentration or attention
    • Thoughts or acts of self-harm or suicide
  • Symptoms are present for at least 2 weeks
  • Mild, moderate, and severe depression
depression across the globe
Depression across the globe
  • Depression is a universal phenomenon
  • Differences in presentation
    • Psychological or somatic symptoms may dominate presentation
    • Belief that depression results from an unknown medical illness, from possession by evil spirits or supernatural powers
    • Related disease models (Patel et al 2001)
      • Thinking too much (kufungisisa) in Zimbabwe
      • Neurasthenia (shenjing shuairuo) in China
      • Anxiety (ghabrahat) in India
      • ‘Heart too much’ (pelo y tata) in Botswana

In China, Suicide is the leading cause of death in persons age 15-34.

In Europe, suicide is the 2nd cause of death in persons 15-34 after traffic accidents.

of women who have contemplated suicide
% of Women who have contemplated suicide

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.

treatment of depression in primary care
Treatment of depression in primary care

WHO: Sartorius et al, 1995.


“The WHO mhGAP Intervention

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?