A Guide to Global Mental Health Practice

Seeing the Unseen

Craig L. Katz, Jan Schuetz-Mueller

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317692829
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Drawing on the authors' experience in developing and implementing global mental health programs in crisis and development settings, A Guide to Global Mental Health Practice: Seeing the Unseen is designed for mental health, public health, and primary care professionals new to this emerging area.

The guide is organized topically and divided into four sections that move from organizing and delivering global mental health services to clinical practice, and from various settings and populations likely to be encountered to special issues unique to global work. Case studies based around a central scene are threaded throughout the book to convey what global mental health work actually involves.

Mental health professionals of all backgrounds, including social workers, nurses, nurse practitioners, psychologists, and psychiatrists, as well as public health professionals and community level medical professionals and mental health advocates will benefit from this engaging primer. It is the book for anyone committed to addressing mental health issues in a low resource or crisis-hit setting, whether international or domestic.

Part 1 Organizing for global mental health

Chapter 1 Epidemiology

DOI: 10.4324/9781315777221-2

Sam walks languidly among the hustle and bustle of the street. He is a farmer who on most any other day other than his church-going Sundays would be out at this hour tending to his rice crops. Today he has left the farm in the hands of his younger brother in order to go see the doctor.

Sam has been feeling tired like never before. He’s also been losing weight like it was his to spare. He fears he has malaria, a disease he lost a much younger sister to several years before. For many in his village, they deal with malaria like it were a passing headache, but he cannot shake it. He wonders if the family has been cursed.

Sam’s farm survived the civil war but barely. Early on he saved most of his land from a fire ignited by nearby carpet-bombing of a warlord, only to have guerillas torch his equipment shed on their march to peace talks. The typhoon soon brought rains that were too much, too late and biblical enough to drown his nascent crops but end the war. When peace came, many of his buyers had just disappeared.

It has been a struggle for Sam and his family, making his lassitude incomprehensible. His great shame for letting his family down fueled today’s three-hour bus ride into the capital city to visit the hospital. The photo captures Sam in mid stroll towards the hospital gates after he disembarked at the central bus stop in the city.

Fatigue can have myriad causes from the non-medical to both physical and psychiatric diagnoses. The medical concept of differential diagnosis captures the framework for identifying the range of likely explanations for someone’s symptom(s). The capable clinician uses their training and acumen to narrow down the possibilities through history taking, physical examination and, where possible, laboratory and other testing. In this chapter, we will discuss the range of possible diagnoses that could explain Sam’s problem by examining population level data about health and mental health conditions as well as experience from the field.

General health considerations

Historically when both health professionals and even the lay public in the developed world thought about the health needs of the developing world, infectious or so-called communicable diseases came to mind. This perception and reality became enshrined in global health policy with the promulgation of the Millennium Development Goals (MDG) in 2000 (United Nations 2014; Sachs & McArthur 2005). The MDG set out eight goals for addressing extreme poverty at the dawn of the new millennium. The eight goals to have been met by 2015 are as follows: eradicating extreme poverty and hunger; achieving universal primary education; promoting gender equality and empowering women; reducing child mortality; improving maternal health; ensuring environmental sustainability; global partnership for development; and, notably, combatting HIV/AIDS, malaria, and other infectious diseases.

Depending upon where we situate his low income country, Sam has good reason for concern about malaria, if not other communicable diseases. According to the WHO, 3.3 billion people worldwide were at risk for contracting malaria in 2011 despite impressive gains made towards eradicating it as part of the MDG (World Health Organization 2014a). Worldwide efforts have made a difference with the other communicable diseases as well, but still there is reason for great concern. In 2012, 8.6 million people worldwide acquired tuberculosis (TB), with over a million dying from it even though the incidence and mortality from TB has been declining (World Health Organization 2014b). Meanwhile, 34 million people were living with HIV/AIDS in 2011, with regions such as sub-Saharan Africa representing a disproportionate portion of the global burden. In that year, 1 in 20 adults in that region had HIV/AIDS (World Health Organization 2014c). Finally, varying gains have been made among the neglected tropical diseases such as schistosomiasis and leprosy (World Health Organization 2014c).

But, there are increasingly concerns about non-infectious diseases around the world. Notably absent from the MDG were chronic medical conditions, otherwise known as non-communicable disease (NCD) (Beaglehole et al. 2007). These include in particular cardiovascular disease (high blood pressure, heart disease, and stroke), chronic respiratory conditions (asthma, emphysema, and related conditions), cancer, and diabetes. At around the time when the world was embarking on its pursuit of the MDG, communicable diseases accounted for around 32 percent of worldwide mortality whereas NCD actually accounted for 59 percent. NCD accounted for 87 percent of deaths in high income countries but also for 54 percent of deaths in low and middle income countries (Magnusson 2009). Importantly, unlike with communicable diseases, studies have shown that basic public health oriented preventative measures such as tobacco cessation and dietary salt reduction can have an impressive impact. Yet, the feeling is that NCD and the highly non-technical solutions to them have not been adequately embraced and prioritized by the WHO (Beaglehole et al. 2007).

From a statistical point of view Sam could be right that he had malaria, and any doctor in an endemic area would be remiss not to consider it as a possible explanation for his fatigue. They likewise might consider TB, neglected tropical diseases, and HIV/AIDS. But, there are increasingly other less dramatic and more insidious possible explanations. Fatigue is a common presentation for new onset diabetes, although typically with other complaints such as intense thirst or frequent urination that his doctor could explore with him. Or, depending upon his age and lifestyle factors such as diet and substance use, Sam could be developing heart disease. If he smoked, he could be developing significant respiratory problems such as emphysema.

Mental health considerations

What about Sam’s mental health? The 2010 Global Burden of Disease, Injuries, and Risk Factors Study (GBD) provides the most comprehensive picture to date of worldwide mortality and morbidity from health as well as mental health conditions (Whiteford et al. 2013). It provides an invaluable perspective on the presence that mental illness has around the world and therefore requires some explaining. Three specific measures were looked at by the GBD investigators, as follows: (1) Years of Life Lost (YLL), which is a measure of premature mortality; (2) Years Lived with Disability (YLD), which is a measure of morbidity; and (3) Disability Adjusted Life Years (DALY), which results from summing YLL and YLD. DALY represents a composite view of the years of life lost to premature death or disability.

As seen in Table 1.1, mental and substance use disorders (they are grouped together) account for only 0.5 percent of worldwide mortality or YLL. Given that problems with mental health more commonly affect quality of life and functioning in daily life rather than threatening life itself, this makes sense. Instead and consistent with what was discussed earlier, four categories account for much of worldwide mortality: cardiovascular disease, cancer, infectious diseases, and neonatal conditions. Conversely, when morbidity or YLD are examined, mental and substance use disorders account for 22.9 percent of global YLD and therefore as a category constitute the number one cause of morbidity. Musculoskeletal disorders are a close second at 21.3 percent, followed by NCD at 11.1 percent. When mortality and morbidity are then examined together in worldwide DALY, mental and substance use disorders are fifth among all causes, following right behind the same top four causes of YLL that were just described (Whiteford et al. 2013).

Table 1.1 Proportion of YLD, YLL, and DALY explained by the ten leading causes of total burden in 2010

	Proportion of total DALY (95% UI)	Proportion of total YLD (95% UI)	Proportion of total YLL (95% UI)
Cardiovascular and circulatory diseases	11.9% (11.0–12.6)	2.8% (2.4–3.4)	15.9% (15.0–16.8)
Diarrhoea, lower respiratory infections, meningitis, and other common infectious diseases	11.4% (10.3–12.7)	2.6% (2.0–3.2)	15.4% (14.0–17.1)
Neonatal disorders	8.1% (7.3–9.0)	1.2% (1.0–1.5)	11.2% (10.2–12.4)
Cancer	7.6% (7.0–8.2)	0.6% (0.5–0.7)	10.7% (10.0–11.4)
Mental and substance use disorders	7.4% (6.2–8.6)	22.9% (18.6–27.2)	0.5% (0.4–0.7)
Musculoskeletal disorders	6.8% (5.4–8.2)	21.3% (17.7–24.9)	0.2% (0.2–0.3)
HIV/AIDS and tuberculosis	5.3% (4.8–5.7)	1.4% (1.0–1.9)	7.0% (6.4–7.5)
Other non-communicable diseases	5.1% (4.1–6.6)	11.1% (8.2–15.2)	2.4% (2.0–2.8)
Diabetes, urogenital, blood, and endocrine diseases	4.9% (4.4–5.5)	7.3% (6.1–8.7)	3.8% (3.4–4.3)
Unintentional injuries other than transport injuries	4.8% (4.4–5.3)	3.4% (2.5–4.4)	5.5% (4.9–5.9)
Source: Reproduced with permission from Whiteford et al. 2013

When all measures are considered, mental and substance use disorders account for 14 percent of the total global burden of disease and are expected to climb to 15 percent by 2020 (Ngui et al. 2010). For Sam, we do not know whether he suffers from a potentially life threatening condition, whether infectious or otherwise. But, we do know that he is concerned about how poorly he has been functioning recently in his work as a farmer. And, so, given its place among disabling conditions in the world’s population, mental and substance use disorders should really be a consideration as one possible explanation for Sam’s lassitude. Now let’s examine what we know about the worldwide scope of the specific mental disorders in order to hone our consideration of mental health reasons for his coming to the doctor.

Depressive disorders

The depressive disorders, or what might be called clinical depression, consist of Major Depression, a typically more intense and episodic mood problem, and Dysthymia, which is by definition more persistent but less intense. Both entail a fundamental complaint involving low mood or loss of pleasure in things but, as syndromes, they also involve a potential range of changes in how people think, act, or feel physically. These encompass disturbances in sleep, appetite, energy level, mental or motor speed, concentration, and self-confidence. At the most extreme, Major Depression can also involve suicide or even psychotic perceptions or thinking (American Psychiatric Association 2013).

In the 2010 Global Burden of Disease study, Major Depression in particular was found to be number two worldwide among all disorders as a cause of years lost to disability. The leading cause was low back pain. Dysthymia was only 19th. In some regions of the world, Major Depression was the leading cause of YLD, including Latin America, Southeast Asia, and Oceania whereas it was otherwise largely second in most other regions, including North America. In DALY, Major Depression was 11th among all causes, and Dysthymia was 51st, as they were not directly associated with any significant mortality. Major Depression was also found to be a contributor to the DALY-based global burden from suicide and, perhaps more surprisingly, heart disease (Ferrari et al. 2013a).

When Major Depression is looked at through the prism of its prevalence, some investigators have found that its overall worldwide point prevalence amounts to 4.7 percent across all available studies in the published literature (Ferrari et al. 2013b). If accurate, this would mean that 4.7 percent of the world’s population suffers from Major Depression at any one time. Researchers also appear to agree that Major Depression is prevalent across all regions of the world, although potentially ...

Table of contents

• Cover Page
• Halftitle Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of figures
• List of tables
• Contributors and acknowledgments
• Foreword
• Introduction: seeing the unseen
• PART 1 Organizing for global mental health
• PART 2 Clinical interventions
• PART 3 Unique practice populations
• PART 4 Special issues
• Appendix: scaling up
• Index