On Burden: A Study of the Population-Level Health-Effects of Mental Illness

Abstract

The burden of disease framework provides a unique tool for rational health systems planning. However, due to methodological constraints it systematically underestimates the burden of mental disorders. I develop a constructive critique of the burden of disease methodology, and a framework to partially correct current estimates. This framework is then applied at different levels -province, country, continent, and globally- with the goal of: (a) adequately informing mental health prioritization and intervention by governments and organizations; (b) detecting disease distribution patterns in countries belonging to different sub-regions and income-levels; (c) understanding the ecological association of group-level poverty and specific mental disorders; (c) quantifying the imbalance between disease burden and government spending on mental health; and (d) making the case for considering the adequate care for mental disorders a global health and development priority. This study of the burden of mental disorders puts it at the top of the disability ranking -and second in the combined ranking of disability and mortality- globally and in the Americas, and provides actionable needs-assessments for governments, multilateral organizations, and non-profits. It provides a life-course perspective on how the epidemiologic transition shapes disease distribution across country-income levels, finds a direct association of the percentage of the population in poverty with group-level depression disability, an inverse association with schizophrenia disability -which can be ascribed to increased lethality in low-income settings-, and a direct effect -controlling for group-level poverty- of disability due to depression in women of child-bearing age on under-five burden due to communicable, perinatal, and nutritional disorders. Also, it finds that the imbalance between burden and spending on mental health -factoring in allocative efficiency- is inversely associated with country income-level in the Americas: poorer countries spend a lower fraction of their health expenditures on mental health and allocate it less efficiently. Finally, I argue that in order to make mental health a global health and development priority, a governance and advocacy effort is required, including the creation of a specific organizational setting of global reach capable of engaging key partners that have so far been elusive, such as Governments, global donors, and economic actors.