Depression accounts for 44.6% of mental health burden in EMR, reveals study

Mental health disorders taking alarming toll on Pakistanis; rates of depression, anxiety in women up to double those in men

Islamabad

Depression accounted for 44.6% of the total disease burden from mental illnesses in the Eastern Mediterranean Region (EMR) in 2013, reveals the first-ever comprehensive study quantifying the burden of mental disorders in EMR.

The study, which has been published in Plos One, an international journal based on the Institute for Health Metrics and Evaluation (IHME), provides vital evidence to prove that chronic disorders including mental illnesses are accelerating in EMR, and given the increased level of instability in countries constituting this region (Pakistan and Afghanistan included), the progression of mental health problems will only reach alarmingly high levels unless measures are instituted now, and on an emergency footing.

Titled ‘The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990-2013,’ the study assesses the fatal, non-fatal and total burden of mental disorders in EMR in 2013 with reference to changes in burden since 1990, using data and methods from the Global Burden of Diseases, Injuries, and Risk Factors Study 2013. It finds the burden of mental disorders being higher in almost all EMR countries compared to the global average. The second-greatest cause of total disease burden from mental illness, after depression, is anxiety. The rate of both of these disorders spikes during adolescence, the study states.

The findings of the study are particularly an eye-opener for countries like Pakistan and Afghanistan, which according to the WHO-Assessment Instrument for Mental Health Systems Study, “allocate little to no money for mental health services.” The study calls upon the ministries of health in EMR countries to increase provision of mental health services, and to address the stigma of mental illnesses, which are a major public health concern and a leading contributor to the global disease burden. In 2013, 5.4% of global DALYs (Disability-Adjusted Life Years) and 17.4% of global YLDs (Years Lived with Disability) were due to mental disorders. About 90% of suicides are due to underlying mental illness, with the WHO estimating an incidence of 800,000 suicides per year in 2005, with 86% being in low and middle-income countries. 

Mental disorders are common in EMR too. Here, depression and anxiety disorders are the most frequent mental disorders, and rates in women are up to double those in men. “In 2013, mental disorders in EMR contributed to 11.9 million DALYs (7.6 million-17.2 million) equivalent to 1,894 DALYS/100,000 population. In comparison, mental disorders contributed to 1,834 DALYs/100,000 globally in 2013,” the study reveals.

According to the study, mental disorders were the leading cause of all nonfatal burden of disease in EMR. In 2013, they accounted for 11.9 million YLDs or 19% of nonfatal burden. Globally, mental disorders contributed to 17.4% of nonfatal burden in 2013, ranking as second-largest contributor to nonfatal burden, following musculoskeletal disorders. Depressive disorders accounted for most YLDs, followed by anxiety disorders, both in EMR and globally.

The study findings reveal that in high-income EMR countries, mental disorders contributed to 2,519 DALYs/100,000 of the population (2,590/100,000 in males and 2,426/100,000 in females). In middle-income countries, mental disorders contributed to 1,884 DALYs/100,000 (1,618/100,000 in males and 2,157/100,000 in females). In low-income countries including Pakistan, mental disorders contributed to 1,607 DALYs/100,000 (1,500/100,000 in males and 1,717/100,000 in females). Globally, mental disorders contributed to 1,623 DALYs/100,000 in males and 2,099 DALYs/100,000 in females.

Mental disorders account for more than 4% of the total disease burden in Pakistan, but women suffer a higher mental health burden. Women in Pakistan lost nearly 1.2 million total DALYs to depression, compared to men’s more than 495,000 DALYs in 2013. Anxiety exhibits a similar gender divide. Women in Pakistan lost over 376,700 total DALYs to anxiety while men lost approximately 212,000 DALYs.

“Mental health disorders are taking an alarming toll on people in Pakistan and throughout EMR. Women – often in the prime of their lives – are losing years of good health to depression, anxiety, and other disorders,” said Dr. Anwar Rafay, epidemiologist and co-author of this study. “This is unacceptable and must be addressed by governments, public health experts, and citizens.”

In EMR, females had a greater proportion of total burden attributable to mental disorders than males of equivalent ages, except for those below 15 years of age, the study finds. The study further shows that the highest rate of DALYs occurred in the 25-49 age group, with a peak in the 35-39 years age group, for both genders combined (5,344 DALYs/100,000), females (3,131 DALYs/100,000) and males (2,213 DALYs/100,000). 

The age pattern in males and females was different, the study shows. In females, DALY rates increased progressively from birth up to age 35-39 (3,131 DALYs/100,000) and then decreased incrementally with age. In males, DALY rates peaked at age 15-19 (2,151 DALYs/100,000) and again at age 35-39 (2,213 DALYs/100,000). 

The burden associated with depressive and anxiety disorders rose abruptly in adolescence. Depressive disorder burden peaked between 40-44 years (1,346 DALYs/100,000); anxiety disorder burden peaked between 20-29 years (523 DALYs/100,000); schizophrenia burden peaked between 35-44 years (367 DALYs/100,000); bipolar disorder peaked between 25-34 years (273 DALYs/100,000); conduct disorder peaked between 10-14 years (507 DALYs/100,000) and intellectual disability peaked between 5-24 years (range between 134-153 DALYs/100,000). ADHD occurred mainly between 5-19 years (range between 16-23 DALYs/100,000).

“The burden of mental disorders in EMR increased from 1,726 DALYs/100,000 in 1990 to 1,894 DALYs/100,000 in 2013 (9.7% increase). Globally, it increased from 1,738 DALYs/100,000 to 1,834 DALYs/100,000 (5.5% increase),” the study informs.

Among income groups in EMR, low-income countries have had a relatively stable burden of mental disorders from 1990-2013, the study states. The burden of mental disorders in middle-income EMR countries, much like the global burden of mental disorders, has seen a slight increase. 

Within the mental disorders group in EMR, depressive disorders accounted for most DALYs, followed by anxiety disorders, schizophrenia, bipolar disorder, conduct disorder, idiopathic intellectual disability, and autism spectrum disorders. All EMR countries had a higher mental disorder burden compared to the global level, except for Egypt.

The study shows mental health as being a pressing priority in EMR. In a discussion on the study, authors call upon EMR countries to enhance political commitment and development of policy and legislative infrastructure pertaining to mental health; to promote studies on prevalence and epidemiology of mental disorders on a national and subnational level; to integrate mental health treatment in medical management of patients; to integrate depression care and medical care in primary care settings; and to provide incentives to hospitals to expand their mental health facilities or create new ones in order to meet future demand. “Moreover, medical schools should incentivize students to specialize in psychiatry training. Finally, awareness campaigns are crucial to encouraging those suffering in silence to seek medical care and speak up about their illness,” the discussion concludes.

“The world is changing and EMR needs to change with it,” said IHME Director for Middle Eastern Initiatives Dr. Ali Mokdad. “With conflicts in many countries in the region, the challenge of mental health for children and adults is likely to increase. We need to equip our health systems to tackle this head-on. That means ramping up treatment options for people with mental health disorders and boosting prevention efforts that will encourage people to seek help.”